REPUBLIC OF THE PHILIPPINES )

PROVINCE OF LAGUNA )
CITY/MUNICIPALITY OF SAN PEDRO ) S.S.

AFFIDAVIT OF SELF-ADJUDICATION

I, <NAME OF HEIR>, of legal age, Filipino Citizen, single, with residence and
postal address at ___________________________________, after having been sworn to in
accordance with law, do hereby depose and state the following:

1. I am the only living, legitimate and immediate heir of <NAME OF THE

DECEASED> (“TATAY”) who was born on _________________;

2. He was legally married to <NAME OF NANAY> (“NANAY”) on 18 <DATE OF

MARRIAGE>;

3. Likewise, during the marriage of TATAY and NANAY, they owned a real
property with improvement (“REAL PROPERTY”) located at the
__________________ containing an area of ______________________ SQUARE
METERS (_______sq. m.), more or less, covered by Transfer Certificate of Title
No. ___________ issued by the Registry of Deeds for the City of _____________
and more particularly described as follows:

“A parcel of land ……..”

A copy of TCT No. ________ is hereto attached as Annex “A”;

4. On ____________, TATAY died. A copy of TATAY’s Death Certificate is hereto

attached as Annex “B”;

5. On _______________, NANAY died at Metro Antipolo Hospital and Medical

Center which is located at __________________________, Rizal, Philippines. A
copy of NANAY’s Death Certificate is hereto attached as Annex “C”;

6. At the time of NANAY’s death, I took care of her at my residence at

__________________________ which now served as her residence at the time of
her death;

7. Based on my personal knowledge and recollection, TATAY and NANAY have

no other siblings whether of the full or half-blood;

8. Likewise, based on my personal knowledge and recollection, I have no other

siblings whether of the full or half-blood;

9. The only property that I am personally aware of that had been left behind by my
TATAY and NANAY is the REAL PROPERTY which is already described
above;

10. The improvement standing on the above-described REAL PROPERTY served as

the principal residence and family home of my TATAY and NANAY during
their lifetime. There could be other properties owned by TATAY and NANAY
but I am not personally aware of them, if any.
 11. I am executing this Affidavit in order to adjudicate unto myself the above-
described REAL PROPERTY covered by TCT No. __________. I reserve the
right to assert my inheritance of other properties that may hereafter be
discovered as properly belonging to my TATAY and NANAY.

12. Affiant further sayeth naught.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

_____th day of _________________________, 2021 in San Pedro, Laguna, Philippines.

<NAME OF HEIR>
Affiant

SUBSCRIBED AND SWORN to before me, this ____th day of

_________________________, 2021 in San Pedro, Laguna, affiant exhibiting to me his I.D.
with No. ______________________________.

Notary Public

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2021.