AFFIDAVIT OF ADJUDICATION BY SOLE HEIR OF

ESTATE OF DECEASED PERSON

REPUBLIC OF THE PHILIPPINES

PROVINCE OF PANGASINAN
MUNICIPALITY OF URBIZTONDO

AFFIDAVIT

I, NATALIA BANAAG SARMIENTO, of legal age, married to MARCIANO

PALISOC SARMIENTO and now residing at Brgy. Malibong Urbiztondo, Pangasinan,
Philippines, after having been sworn in accordance with law, depose and say:

1. That I am the only surviving daughter-in-law of one, named MARIA PALISOC who
died interstate in the Municipality of Urbiztondo, Pangasinan, Philippines, on _________
as evidence by Death Certificate issued by the Philippine Statistics Authority hereto
attached as ANNEX “A” and made an integral part of this Affidavit;

2. That said deceased left an estate consisting of a parcel of land measuring 58 sq.m.,
located in the Municipality of Urbiztondo, and evidenced by Transfer of Title No.
_______ of the Registry of Deeds of Lingayen, Pangasinan;

3. That the said parcel of land is more particularly described as follow to wit:

(Description)

4. That said deceased left no debts;

5. That the net value of said estate is not more than _________________________,
and is therefore exempt from the estate and inheritance taxes, as evidenced by a
certificate of exemption issued by the Bureau of Internal Revenue hereto attached as
ANNEX “B” and made an integral part of this affidavit;

6. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate unto
myself the above described real estate by means of this Affidavit and hereby files same
with the Register of Deeds of _______________ with the request that said adjudication
be made effective without judicial proceedings as prescribed by the aforementioned
Rules ofCourt.
 IN WITNESS WHEREOF, I have hereunto set my hand this day of
______________________, 20___, in the ______________________, Philippines.

________________
(Signature of Affiant)

JURAT