Republic of the Philippines)

Province of Nueva Ecija ) S.S.

Municipality of San Isidro )
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AFFIDAVIT OF ADVERSE CLAIM

I, _______________, of legal age, Filipino, widow, and a resident of Brgy.

Pulo, San Isidro, Nueva Ecija, after having been sworn to in accordance with law,
depose and say:

1. That on May 3, 2018, Spouses ________________________________

(the spouses are hereinafter referred to as “________”, for brevity), both of legal
age, Filipinos, and residents of Brgy. Pulo, San Isidro, Nueva Ecija, borrowed
money in the amount of five hundred thousand pesos (Php500,000.00) from me.

2. I agreed to lend the said amount to ___________ due to their

commitment to provide a collateral over a parcel of land which they represented
to be as their own property, albeit the title bearing the name of __________, who
was the deceased father of _______. Furthermore, the _______ claimed that they
will arrange the transfer of title to their respective names at a later date.

3. On the same day, the ___________ gave me the original Transfer

Certificate of Title (“TCT”) No. ____________ (now, TCT No. ____________) over
the aforementioned parcel of land to serve as a security of the loan. The
execution of the loan agreement and its security/collateral over a parcel of land,
and the receipt of the loan proceeds by _______, are all evidenced by a Katibayan
dated May 3, 2018. A copy of the Katibayan is attached hereto and made an
integral part hereof as Annex “A”.

4. The security/collateral over the parcel of land gave me the right to

use or till the land for a period of three (3) years from the date of execution of the
loan or until the loan amount has been paid (“the Stipulation”).

5. The parcel of land has an area of 9,923 square meters (sqm.) and is
located at Barrio Pulo, San Isidro, Nueva Ecija, more particularly described as
follows:

TECHNICAL DESCRIPTION

6. On May 29, 2019, _____ instead offered to sell the parcel of land
(security/collateral) to me for an additional Php500,000.00 (therefore, the sale
amount is at Php1 million, including the first Php500,000 given to the ______ by
way of loan). However, considering that the transfer of title to the ________’s
names was still not arranged, I decided to give only an additional Php300,000.00,
which served as an amendment to the original loan agreement, evidenced by the
aforementioned Katibayan. This time, the amended loan agreement (with the total
loan amount of Php800,000.00) was evidenced by a Kasunduan dated May 29,
2019, which was executed before the Office of the Punong Barangay. The said
Kasunduan contains the Stipulation previously mentioned (with an amended
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reckoning date of May 29, 2019). A copy of the Kasunduan is attached hereto and
made an integral part hereof as Annex “B”.

7. Nonetheless, we had an internal agreement that once the title has

been legally transferred to them, an additional two hundred thousand pesos
(Php200,000.00) will be given by me and a Deed of Absolute Sale will be made.

8. In August 2021, _____ approached me and asked for the copy of the
original title for the reason that they will process the transfer of title so that we
can proceed with our internal agreement. In good faith, I decided to return the
original copy of the title to her. Little did I know that I was already being
deceived by ______.

9. Thereafter, I have made several follow-ups on the status of the

transfer of title and/or demands for the ________ to return the title to continually
serve as my security over the Php800,000.00 loan. However, all my requests
remained unheeded.

10. To date, the entire loan amount of _______ remains unpaid, and the
internal agreement between the parties to execute a subsequent sale never
pushed through.

11. It has very recently come to my knowledge that the ________ was
able to transfer the title to their names, now under TCT No. _________, and
therefore, I am executing my right to protect my claim over the security of the
loan, unless and until the amount that they were able to borrow from me is paid
in full.

12. That unless an adverse claim is annotated on the afore-described

Transfer Certificate of Title, my right over the security of the loan is in danger of
being impaired, and as such, I am executing this Affidavit in support of my
request for the annotation of an adverse claim over the parcel of land described
herein.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________, in the Municipality of San Isidro, Nueva Ecija, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME THIS _____________,

Affiant personally presented to me her _____________ ID, bearing No.
________________, and issued/expiring on __________________, issued at
_____________________, as a valid and acceptable proof of her identity.

Doc. No. _______;

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Page No. _______;

Book No. _______;
Series of 2022.