REPUBLIC OF THE PHILIPPINES )

Province of )
City / Municipality of ) S.S.

AFFIDAVIT OF ADVERSE CLAIM

I, Juan Dela Cruz, of legal age, Filipino, single / married to ---, a resident of 1234Abakada St., --- City,
after being first duly sworn under oath, depose and state:

1. That Pedro is the registered owner of a parcel of land situated at --------- covered by TCT No. 123456,
with a total area of -----sq.m.;
2. That by virtue of a Deed of Absolute Sale acknowledged on (Date) before a Notary Public under
Document No. ---, Page No. ---, Book No. ---, Series of 2010, Pedro sold the abovementioned parcel of
land to me;
3. That despite repeated demands, Pedro refuses and to date, still refuses without reasonable cause to
surrender the Transfer Certificate of Title No. 123456 in order to effect the transfer and registration of
said land in my name;
4. That I am executing this affidavit for the purpose of protecting my right and for having said right
annotated.

In witness whereof, I have hereunto set my hand this --- day of ------, 2010.

Juan Dela Cruz

Affiant

SUBSCRIBED AND SWORN TO before me a Notary Public for the City / Municipality of -----, affiant
exhibiting to me his (gov’t issued i.d.) issued on ---- at -------.

Atty ------------
Notary Public
Roll No. 12345
IBP O.R. 123456 ; Jan-1-2010
PTR No. 123456 ; Jan-1-2010
(Address)
-------- expires December 31, 2010

Doc No. ;
Page No. ;
Book No. ;
Series 2010.