Republic of the Philippines )

City of San Fernando )

Province of Pampanga )ss

AFFIDAVIT OF ADVERSE CLAIM

I, _________, of legal age, Filipino, and a resident of ___________________, after

having been duly sworn to in accordance with law, depose and state:

1. That on 11 August 2011, I have entered into a Deed of Donation which was acknowledged
on the same date before ____________ and entered in his Notarial Register as ________. A
copy of the said Deed is hereto attached as ANNEX A and made an integral part of this
Affidavit;

2. That in the said Deed of Donation, I was the DONEE of parcels of land covered by

xxx

4. However, ________;

5. I am therefore executing this Affidavit for the purpose of attesting to the truthfulness of
the foregoing allegations and in support of my request for the annotation of an adverse
claim over the parcel of land covered by the Transfer Certificate of Title No__________.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of February
2017 in __________.

_________________________
Affiant

SUBCRIBED AND SWORN TO before me this ___ day of February 2017 in

____________, affiant exhibiting to me his __________ issued in ________ and valid until
__________.