REPUBLIC OF THE PHILIPPINE}

DONE: IN THE CITY OF BAGUIO}S.S.

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AFFIDAVIT OF ADJUDICATION
I, of legal age, single/married to __________________ and now residing a
t _________________, Philippines, after having been sworn in accordance
w i t h l a w,depose and say:1.That I am the only surviving son of one, named
________________ who diedintestate in the municipality of __________________,
Philippines, on
_______________ a s e v i d e n c e d b y D e a t h C e r t i f i c a t e i s s u e d b y t h e _ _ _ _ _ _ _ _ _
_ _ _ _ h e r e t o a t t a c h e d a s ANNEX A and made an integral part of this Affidavit;2 . T h a t
said deceased left an estate consisting of a parcel of land
m e a s u r i n g _______________ sq. m., located in the municipality of _____
_ _ _ _ _ _ _ _ _ _ _ , a n d evidenced by Transfer of Title No. _________________ of the
Registry of Deeds of ________________;3.That the said parcel of land is more
particularly described as follows, to wit: TTRANSFER CERTIFICATE OF TITLE NO. T_______ TECHNICAL DESCRIPTIONSLOT ______ "A PARCEL OF LAND (Lot ____,
____________), situated in the _________________. Bounded on the
____________________________.Beginning at a point marked "1" on plan, being
________________;
pointo f b e g i n n i n g c o n t a i n i n g a n a r e a o f _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (
_ _ _ _ _ ) SQUARE METERS, more or less. All points referred to are indicated
on plan and are marked on the ground as follows:_____________." 4 . T h a t s a i d d e c e a s e d
left no debts;5 . T h a t t h e n e t v a l u e o f s a i d
e s t a t e i s n o t m o r e t h a n t h r e e t h o u s a n d p e s o s (P3,000.00), and is
therefore exempt from the estate and inheritance taxes, as evidenced by a certificate of
exemption issued by the Bureau of Internal Revenue hereto attached asANNEX B and made
an integral part of this affidavit;6 . T h a t p u r s u a n t t o R u l e 7 4 , S e c . 1 o f t h e R u l e s o f
C o u r t , I h e r e b y a d j u d i c a t e unto myself the above described real estate by means
of this Affidavit and hereby files same with the Register of Deeds of ____________ with the
request that said adjudication
be made effective without judicial proceedings as prescribed
by the aforementionedRules of Court.IN WITNESS WHEREOF, I have hereunto set my hand
this ___________ day of ___________________, 200_ in _________________, Philippines.
(Signature over Printed
Name)AffiantS U B S C R I B E D a n d s w o r n t o b e f o r e m e , i n t h e c i
t y / m u n i c i p a l i t y o f _______________, this _______ day of
_____________, 200_ by ____________ withCommunity Tax Certificate No.
_________________ issued at ________________ on __________, 200_. NOTARY
PUBLICMy commission expires on Dec. 31, 20