Sample Affidavit of Self-

Adjudication by Sole Heir

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REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.
x-------------------------------------x

AFFIDAVIT OF SELF-ADJUDICATION

I, MARIA B. DELA CRUZ, of legal age, Filipino, single and a

resident of 6789 Washington Street, Pio del Pilar, Makati City, after
having been duly sworn to in accordance with law, depose and
state:

1. That I am the only daughter of JUAN B. DELA CRUZ who died

without any last will and testament on July 20, 2013 in Makati
City as evidenced by his Death Certificate issued by the City of
Makati hereto attached as Annex “A” and made an integral part of
this Affidavit;

2. That at the time his death, my father had no debts, liabilities or

obligations to any persons, agency or institution;

3. That the only property he left is a parcel of land consisting of 60

square meters located in J.B. Roxas Street, Makati City more
particularly described in TCT No. 112233 hereto attached as Annex
“B” and made an integral part of this Affidavit;

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

adjudicate unto myself the above-described real estate by means of
this Affidavit and hereby files the same with theRegister of Deed of
Makati City with the request that the said adjudication be made
effective without judicial proceeding as prescribed by the
aforementioned provision of the Rules of Court.

IN WITNESS WHEREOF, I have hereunto set my hand this

26th day of September 2013 in Makati City, Metro
Manila, Philippines.
 MARIA B. DELA CRUZ

Affiant

SUBCRIBED AND SWORN TO before me this 26th day of

September 2013 in Makati City, Metro Manila, Philippines, affiant
exhibiting to me her Philippine Passport No. 123456 issued in Manila
on January 12, 2012 and valid until January 12, 2017.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.