REPUBLIC OF THE PHILIPPINES )

QUEZON CITY, METRO MANILA)

AFFIDAVIT OF ADVERSE CLAIM

I, Alejandro Mejica, of legal age, Filipino, married and residing in Sitio Catmon, Brgy. San
Rafael, Rodriguez, Rizal, after having been sworn according to law, hereby depose and say:

1. That on _____________________________, I have entered into a contract denominated as

Memorandum of Agreement, Deed of Assignment and Irrevocable Special Power of Attorney
with the Heirs of Pable Gelito thru their duly and legal representative Fermin G. Dayao, which
was notarized on _____________________ before Notary Public _____________________ of
_______________________ and entered in his Notarial Register as Doc. No. ___, Page __,
Book ___, Series of 201__. A copy of the said instrument is hereto attached as Annex “A” and
made as an integral part of this Affidavit;

2. That in the said Memorandum of Agreement, Deed of Assignment and Irrevocable Special
Power of Attorney, I am one of the ASSIGNEES and REPRESENTATIVE of Heirs of Pable Gelito
with regard to a certain parcel of land covered by Tax Declaration No.
_______________________ containing an area of __________________________
situated in _______________________________;

3. That said instrument or contract is self-explanatory to render herein affiant to have lawful
claims over the aforesaid property;

4. I am therefore executing this Affidavit for the purpose of attesting to the truthfulness of the
foregoing claims and allegations and in support of my request for the annotation of said
Memorandum of Agreement, Deed of Assignment and Irrevocable Special Power of Attorney as
an adverse claim over the parcel of land covered by Tax Declaration No.
__________________.

IN WITNESS WHEREOF, I have hereunto set my hand this ___th day of June 2016 in
Quezon City, Metro Manila, Philippines.

ALEJANDRO MEJICA
Affiant
________________
________________

SUBCRIBED AND SWORN TO before me this ______ day of July 2016 in Quezon City,
Metro Manila, Philippines, affiants exhibiting to me their ID indicated below their names.

Doc. No. _____; Notary Public

Page No. _____;
Book No. _____;
Series of 2017.