AFFIDAVIT OF SELF – ADJUDICATION

WITH DONATION

KNOW ALL MEN BY THESE PRESENTS:

That I, ___________________________, of legal age, Filipino, widow of the late

______________________ and resident of ______________________, ________________________,
___________________________________, after having been duly sworn to in accordance with law, do hereby
depose and say;
That I am the surviving spouse of the late ________________________________, who died intestate
without any will or testament sometime on _____________________ leaving a parcel of land, more
particularly described and bounded as follows:

“A riceland situated at _________________________, __________________________,

_______________________. Bounded on the N. by property of Tomas Velasco; on the E. by property
of Cirilo Cervantes; on the S. by property of Dalmacio Fabro; and on the W. by property of Ursula
Caoagdan, containing an area of NINE THOUSAND SEVEN HUNDRED SIXTEEN ( 9,716 )
Square Meters, more or less, covered by Tax Declaration Number ________________________ of
the Municipal Assessor Office of _______________________, ________________________.”

That said decedent left no known debts and that no personal properties are involved in this Affidavit of
Self Adjudication with Donation;
That by these presents ,being the sole surviving heir of the decedent, invoking Section 4 of Rule 74 of
the Rules of Court and by means of this affidavit, I adjudicate unto myself ownership of the above described
real property and forthwith dispose the same to third person on the following:

DONATION

That for and in consideration of my love and affection to my children

________________________________ m/to ___________________________ and
______________________________ m/to _________________________ also of legal ages, Filipinos and
residents of Nancamaliran, Urdaneta, Pangasinan and ___________________________ hereinafter called the
DONEES do by these presents hereby CEDE and DONATE unto the said DONEES, their heirs and assigns
the above described real property, free from liens and encumbrances, and hereby warrant peaceful possession
and ownership over the above described real property donated to the herein donees and shall defend its title
against any and all claims from third persons whomsoever.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________ day of

____________________ 2010 at ____________________, ___________________________.

____________________
Donor
CTC No.
Issued on
Issued at

SIGNED IN THE PRESENCE OF:

1. ________________________ 2. __________________________

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF )S.S.
MUNICIPALITY )

BEFORE ME, this _________ day of _________________,2010 at ______________________,

________________________ personally appeared the aboved named Donor known to me to be the same
person who executed the foregoing instrument and hereby acknowledged that the same is his free act and
voluntary deed.
WITNESS MY HAND AND SEAL .