Republic of the Philippines)

Quezon City, Metro Manila) S.S.

AFFIDAVIT OF SELF-ADJUDICATION

I, ______________________________, of legal age, single/married, Filipino and

a resident of ___________________________________________, Quezon City after
having been duly sworn to in accordance with law, depose and say:

1. To the exclusion of others, I am one of the legitimate heir of the late

_____________________________ who died on ____________________ at
____________________________ without leaving a will ;

2. That I am claiming for his/her ______________________ benefit from the

DSWD SAP from Quezon City;

3. I acknowledge the said benefit free and harmless from any and all actions
that may arise from the release thereof;

4. By virtue of this affidavit I shall be held liable to any person that may be
prejudiced by my representations in addition to other liabilities that may arise
therefrom;

5. I undertake to refund the amount paid to me for any loss or damage

occasioned by such payment.

AFFIANT FURTHER SAYETH NONE.

_____________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of ______________

2021 in Quezon City affiant with competent proof of identity bearing his/her
signature and photograph.

Doc. No. _____

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