Republic of the Philippines )

Province of Davao del Norte ) S.S

City of _________                   ) 
x-------------------------------------x
  

AFFIDAVIT OF SELF-ADJUDICATION

         I, ____________ of legal age, Filipino, single and a resident of

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

1. That I am the only daughter of ______________ who died without any

last will and testament on ________ in ______ 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 the Register 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

________________ in ____________, Philippines.
          

________________
Affiant

    SUBCRIBED AND SWORN TO before me this _____________ in

_______, _________, Philippines, affiant exhibiting to me her (ID) issued in
______ on _________ and valid until January 12, 2017.

Doc. No. _____;

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