Republic of the Philippines)

Municipality of San Nicolas) S.S

AFFIDAVIT OF SELF-ADJUDICATION

I, PATRICIA V. BAUTISTA, of legal age, widow, American citizen and a resident of 558
Kamehameha Avenue, Kahului, Maui, Hawaii, USA and with Philippine address at Brgy. 30,
Cadaratan, Bacarra, Ilocos Norte, after having been duly sworn to in accordance with law, do
hereby depose and state:

That I am the only surviving heir being the lawful wife of the late Jose I. Bautista who
died on February 11, 1911, (copy of the Death Certificate is hereto attached as Annex “A” and
made an integral part hereof) who left a certain parcel of land covered and embraced by Tax
Declaration No. 14-036-00929 pertaining to Lot No. 38809, more particularly described as
follows, to wit:

TAX DECLARATION NO. 14-036-00929

Agricultural Lot with an area of 300 square meters bounded

on the North by Lot No. 038; on the East by Lot No. 040; on the South
by Lot no. 042 and on the West by Lot No. 040, with an assessed value
of Php 3,000.00

That at the time of his death, said decedent left no will or obligation;
That it is to the best of my interest that I hereby ADJUDICATE unto myself the above-
described parcel of land;

That I am executing this Affidavit of Self-Adjudication with Deed of Absolute Sale to

attest to the veracity and truthfulness of the foregoing statements and for all legal intents and
purposes it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ________day of July,

2020 at San Nicolas, Ilocos Norte, Philippinses.

PATRICIA V. BAUTISTA
Affiant-Vendor

USA Passport No. 572934158

Issued on January 17, 2018

Expiry date on January 16, 2028

Witnesses:

__________________________ _____________________________
Republic of the Philippines )
Municipality of San Nicolas ) S.S

ACKNOWLEDGMENT

Before me, a Notary Public, for and in the Municipality of San Nicolas, Ilocos Norte, this
th
9 day of March, came and personally appeared the above-named party and presented to me
her respective Identification stated above her name, and fully acknowledged to me that this
instrument is her own free will and deed.

I further certify that this foregoing instrument consisting of two (2) pages, including
where this Acknowledgment is written and it relates to an AFFIDAVIT OF SELF-ADJUDICATION
over a parcel of agricultural land located at Bacarra, Ilocos Norte, signed by the Affiant, and
her instrumental witnesses thereto.

WITNESS MY HAND and NOTARIAL SEAL.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2020.