Republic of the Philippines)

________………………………)S.S.
x----------------------------/

AFFIDAVIT OF ADVERSE CLAIM

I, ________ of legal age, Filipino, _____, ____ and a resident of ______________, after having been duly
sworn to in accordance with law, do hereby depose and state that:

1. I am executing this affidavit pursuant to Section 70 (Adverse claim) of PD 1529 or the PROPERTY
REGISTRATION DECREE;

2. All notices pertinent to my Adverse Claim may be served upon me at my aforementioned residence;

3. I sold a certain parcel of land situated in ___________, containing an area of _________________,

more or less, covered under Transfer Certificate of Title No. _____, to _______________, pursuant
to a Deed of Absolute Sale dated _________ and found under Document No. ___, Page No. ___,
Book No. ___ and Series of ___ of the Notarial Register of _______________;

4. Although the Deed of Absolute Sale was executed and acknowledged, the vendee LEFT and FAILED
to fully or partially convey to me the amount in consideration of the sale;

5. I hereby file an adverse claim against ________________ before the Register of Deeds of Butuan
City, to protect my rights and interest over the said parcel of land;

6. I am executing this affidavit to file an adverse claim before the Register of Deeds and City Assessors
Office being the vendor of the above-described property.

IN WITNESS WHEREOF, I do hereby set my hand this this _______ day of _________ in
_______________________.

______________________________________
Affiant
I.D. No.:
Issued on:
Issued at:

JURAT

SUBSCRIBED AND SWORN to before me, this _______ day of _________ in _________. Affiant
exhibited to me the aforementioned identification as her competent evidence of identity.

Doc. No. ______;

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