REPUBLIC OF THE 

PHILIPPINES)
CITY OF MAKATI                      ) S.S.
  

AFFIDAVIT OF SELF-ADJUDICATION

         I, ____________, of legal age, Filipino, widow and a resident of _________, after having
been duly sworn to in accordance with law, depose and state that:

1. I am the surviving spouse and only heir of ___________(the “decedent”), ______

citizen, who died without any last will and testament on _______ in __________City,
Philippines as evidenced by his Death Certificate issued by Parañaque City hereto
attached as Annex “A” and made an integral part of this Affidavit. 

2. At the time his death, the decedent had no debts, liabilities or obligations to any

persons, agency or institution.

3. The decedent left the following the properties:

Real Properties
TCT/CCT No. Location Area (in sqm)

Personal Properties – Shares of Stock

Personal Properties – Motor Vehicle

MAKE/TYPE: MOTOR/ENGINE NO.:
SERIES: CHASSIS NO.:
YEAR MODEL: PLATE NO.:
BODY TYPE: CERTIFICATE OF
REGISTRATION NO.

4. Pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate unto myself the
above-described properties by means of this Affidavit and hereby files the same with
the Register of Deed of the applicable local government unit with the request that
the said adjudication be made effective without judicial proceeding as prescribed by
the aforementioned provision of the Rules of Court.

         IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of _____________
2021 in ____________________City, Metro Manila, Philippines.
          

1
 Affiant

    SUBCRIBED AND SWORN TO before me this ___ day of _____________

2021 in _______________ City, Metro Manila, Philippines, affiant having been identified by
exhibiting to me her competent evidence of identity ___________ issued on __________.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2021.