Sole Heir of Deceased Depositor I

(For P20T & below)

Republic of the Philippines )
Municipality/City of _________) S.S.
Province of ____________)

AFFIDAVIT OF SELF-ADJUDICATION
I, ________________________________, after having been sworn to in accordance with law,
hereby depose and state that I:

1. Am of legal age, Filipino, single/ married, and a resident of

____________________________________________________;

2. To the exclusion of all others, am the only legitimate heir of

__________________________________________ (name of deceased depositor);

3. Hereby certify that the deceased, __________________________________________,

has no other bank deposit in the Philippines;

4. Am claiming from the Philippine Deposit Insurance Corporation (PDIC) the deposit
insurance due on Savings/ Time/ Current Deposit Account No/s. ________________
maintained with ________________________________________ under the name of the
deceased ______________________________________________;

5. Acknowledge receipt of the insurance proceeds, in cash (if the amount is P5,000 &
below) or in check made payable to me, and hold PDIC free and harmless from any and
all actions that may arise from the release of the insured deposit to me;

6. By virtue of this Affidavit, shall be held liable to any person that may be prejudiced by
my representations, in addition to other liabilities, civil or criminal, that may arise
therefrom; hereby releasing and discharging PDIC from any and all further obligations in
connection with this claim;

7. Undertake to refund PDIC the amount paid to me including interest thereon and
indemnify PDIC, the bank and/or third parties for any loss or damages occasioned by
such payment.

I am executing this affidavit to attest to the truth of the foregoing facts.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of

____________________ at _________________________________.

_____________________________
Affiant

SUBSCRIBED AND SWORN to before me in the Municipality/City of __________________ this

____ day of __________________ by the affiant, who has satisfactorily proven his/her identity to me through
his/her _______________________________________ issued on _________________ in
_________________, that he/she is the same person who personally signed the foregoing affidavit before me
and acknowledged that he/she executed the same.

Notary Public
Doc. No. ________ ;
Page No. ________ ;
Book No. ________ ;
Series of ________ .