Republic of the Philippines )

Municipality/City of Cebu ) S.S.

Province of Negros Occidental)
AFFIDAVIT OF SELF-ADJUDICATION
I, Leo kogmaw, after having been sworn to in accordance with law, hereby depose and state
that I: 1. Am of legal age, Filipino, single/ married, and a resident of Ka Menchie, Cebu City; 2.
To the exclusion of all others, am the only legitimate heir of Tarok Kamagong (name of
deceased depositor); 3. Hereby certify that the deceased, Tarok Kamagong, has no other bank
deposit in the Philippines; 4. Am claiming from the Philippine Deposit Insurance Corporation
(PDIC) the deposit insurance due on Savings/ Time/ Current Deposit Account No/s 0564156
maintained with 0564156 under the name of the deceased Tarok Kamagong; 5. Acknowledge
receipt of the insurance proceeds, in cash (if the amount is P5,000 & below) or in check made
payable to me, and hold PDIC free and harmless from any and all actions that may arise from
the release of the insured deposit to me; 6. By virtue of this Affidavit, shall be held liable to any
person that may be prejudiced by my representations, in addition to other liabilities, civil or
criminal, that may arise therefrom; hereby releasing and discharging PDIC from any and all
further obligations in connection with this claim; 7. Undertake to refund PDIC the amount paid
to me including interest thereon and indemnify PDIC, the bank and/or third parties for any loss
or damages occasioned by such payment. I am executing this affidavit to attest to the truth of
the foregoing facts. IN WITNESS WHEREOF, I have hereunto set my hand this November 17 of
Tuesday at 5:00 PM.
_________ Leo Kogmaw________
Affiant
SUBSCRIBED AND SWORN to before me in the Municipality/City of Cebu City this
November 17 day of Tuesday by the affiant, who has satisfactorily proven his/her identity to me
through his/her affidavit issued on December 20 in Friday that he/she is the same person who
personally signed the foregoing affidavit before me and acknowledged that he/she executed
the same.

Notary Public
Doc. No. 0562 ;
Page No 589 ;
Book No. 18 ;
Series of 2000-2001 .