Republic of the Philippines )

Province of ----------- ) S.S.

Municipality of ------------ )
X------------------X

AFFIDAVIT OF SELF-ADJUDICATION

I, -------------------, after having been sworn to in accordance with law,

hereby depose and state that:
1. I am of legal age, Filipino, single, and a resident of -------------------;

2. That to the exclusion of all other heirs, I am the only legitimate

heir of the late, ---------------------, who both died intestate without a
last will and testament, sometime on -------------- and
-------------------;
Attached hereto is a copy of the DEATH CERTIFICATE of my
deceased sister and aunt as ANNEX “A” and “B” and made
an integral part hereof;
3. That I am related to both deceased, and that I am the sister of
-------------, and I am the niece of -------------------------------.

4. That my aforementioned deceased sister and aunt left a joint

savings account with the -------------------------, with Account
No.-------------------;

5. That the said bank account contains a total amount of

---------------------------- Pesos and ----------------------

6. That all of the said deceased ------------ and ---------------- left no

debts;

7. I hereby certify that all of the deceased, ----------------- and

-------------------------------------, has no other bank deposit in the
Philippines;

8. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby

adjudicate unto myself the said ----------------and the money
deposited therein containing ----------------------------------), which
represents my lawful inheritance/share , and hereby files the same
with the ----------------------- Branch with the request that said
adjudication be made effective without judicial proceedings as
prescribed by the aforementioned Rules of Court;

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 9. That I am executing this affidavit to attest to the truth of the
foregoing facts for all legal intents and purposes and I further
certify that the contents of this affidavit has been duly explained to
me in the dialect that I understand and speak, that is, in the
--------------

IN WITNESS WHEREOF, I have hereunto set my hand this --------------

at -------------------

---------------------
Affiant

SUBSCRIBED AND SWORN to before me on the date and place

above stated by affiant, --------------------- who have satisfactorily proven to
me her identity through her -------------------------------, to be the same
person who presented and personally signed before me this Affidavit of
Self Adjudication and attested that the contents thereof are true and
correct; and that she voluntarily executed the same.

Doc. No________;
Page No. _______;
Book No. _______;
Series of 2022.

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