REPUBLIC OF THE PHILIPPINES)

In the CITY OF COTABATO )Sc.

X-------------------------------------------X

AFFIDAVIT OF SOLE ADJUDICATION OF ESTATE OF DECEASED PERSON

RE: UNCLAIMED SALARY

I, NORODIN M. BENITO of legal age of legal age, Filipino, widower, and a resident of
Bagua II, Cotabato City, after having been duly sworn to law, deposed and state:

1. That I am the surviving legal heir/husband of the late NORJANA M. HUSAIN who
died on March 21, 2015 at Digos, Davao del Sur;

2. That at the time of her death she left an Unclaimed Salary as member of Davao Del
Sur United Asatidz Association Inc., (DASCUAA) in the amount of P15, 000.00
representing three (3) month salary from Capitol Provincial Government of Davao del
Sur;

3. That I HEREBY adjudicate to myself the said Claim benefits being the legal heir/son
of the late NORJANA M. HUSAIN;

IN WITNESS WHEROF,I have hereunto set my hand this 18 th day of June, 2015 at
Cotabato City, Philippines.

NORODIN M. BENITO
(Affiant)

SIGNED IN THE PRESENCE OF:

1. AMER MUDSOR 2. KARIM SOLAIMAN

SUBSCRIBED AND SWORN to before me this 18 th day of June, 2015 at Cotabato City,
Philippines, affiant exhibited to me his CTC/ID No. _____________, issued at ______________,
on __________________.

Doc. No. 2435

Page No. 487
Book No. XII
Series of 2015