Republic of the Philippines )

Municipality/City of _________ ) S.S.

Province of _________________)

AFFIDAVIT OF SELF-ADJUDICATION
I, Sole Heir of Deceased Depositor I (For P20T & below)________________________________, after
having been sworn to in accordance with law, hereby depose and state that I:

1. Am of legal age, Filipino, single/ married, and a resident of

____________________________________________________;

2. To the exclusion of all others, am the only legitimate heir of

__________________________________________ (name of deceased depositor);

3. Hereby certify that the deceased, __________________________________________, has no other

bank deposit in the Philippines;

4. Am claiming from the Philippine Deposit Insurance Corporation (PDIC) the deposit insurance due on
Savings/ Time/ Current Deposit Account No/s. ________________ maintained with
________________________________________ under the name of the deceased

5. Acknowledge receipt of the insurance proceeds, in cash (if the amount is P5,000 & below) or in check
made payable to me, and hold PDIC free and harmless from any and all actions that may arise from the
release of the insured deposit to me;

6. By virtue of this Affidavit, shall be held liable to any person that may be prejudiced by my
representations, in addition to other liabilities, civil or criminal, that may arise therefrom; hereby
releasing and discharging PDIC from any and all further obligations in connection with this claim;

7. Undertake to refund PDIC the amount paid to me including interest thereon and indemnify PDIC, the
bank and/or third parties for any loss or damages occasioned by such payment. I am executing this
affidavit to attest to the truth of the foregoing facts. IN WITNESS WHEREOF, I have hereunto set my
hand this _______ day of ____________________ at _________________________________.
_____________________________ Affiant SUBSCRIBED AND SWORN to before me in the
Municipality/City of __________________ this ____ day of __________________ by the affiant, who
has satisfactorily proven his/her identity to me through his/her
_______________________________________ issued on _________________ in _________________,
that he/she is the same person who personally signed the foregoing affidavit before me and
acknowledged that he/she executed the same.

Notary Public

Doc. No. ___________;

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