REPUBLIC OF THE PHILIPPINES)

CITY OF __________ ) S.S

AFFIDAVIT OF SELF-ADJUDICATION

We, _______________________ and _____________________, both of legal age,

Filipino, single, all residents of ____________________, Philippines, after having been sworn
in accordance with law, hereby depose and state that:

1. To the exclusion of all others, we are the only legitimate heirs of the late ___________,
who died on _____________ at ____________________;

2. The decedent died intestate or without leaving a will;

3. The decedent left no debts;

4. The death benefits and insurance attributable to his SSS Benefits became a part of
his estate upon his death;

5. He acquired a real property, specifically a house during his marriage with me at

__________________________________ sometime in the year _____;

6. We are adjudicating unto ourselves the aforesaid death benefit and/or insurance
proceeds and real property left by the decedent _____________;

7. We are executing this affidavit to attest to the truthfulness of the foregoing statements
and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands this ___th day of
____________ 2022 at _________________, Philippines.

SUBSCRIBED AND SWORN TO before me this _____ day of _____________ 2022 at

_______________, Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2022.