REPUBLIC OF THE PHILIPPINES )

Province of Cavite                            ) S.S.

AFFIDAVIT OF ADJUDICATION

I, ABC, of legal age, married, and with address at Amadeo, Cavite, after being duly
sworn to in accordance with law, hereby depose and state:

1. THAT I am the daughter, and one of the legal heirs of the deceased, XYZ, who died
on SEPTEMBER 23, 2008 at Amadeo, Cavite. Attached herein as Annex “A” a copy
of her death certificate.

2. THAT during her lifetime, she owned a property located at Amadeo, Cavite which is
covered by Tax Declaration No. 02-0020-0089552. Herein attached as Annex “B” a
copy of the said Tax Declaration.

3. THAT my mother left no debt or any obligation from anyone;

4. THAT as such heir of the above-mentioned decedent, I hereby adjudicate unto

myself a portion of the above described property where my house is currently
located.

5. THAT I have executed this affidavit to attest the truth of the foregoing facts and for
the purpose of application for electricity line from MERALCO.

IN WITNESS WHEREOF, I hereunto affix my signature this _________________ at

Amadeo, Cavite, Philippines.

                                                                              ABC

                                                                                                        
Affiant

SUBSCRIBED AND SWORN to before me this _______________ at Amadeo, Cavite,

Affiant exhibiting to me her _________________________

NOTARY PUBLIC
Doc No. ______;
Page No. ______;
Book No. ______;
Series of 2020.