Republic of the Philippines )

_____________________ ) SS.

x- - - - - - - - - - - - - - - - - - - - - x

AFFIDAVIT OF SURVIVING LEGAL HEIRS

We, ____________________, ____________________, ____________________, of legal age,

____________________, ____________________, Filipino and resident of ________________,
_______________, ________________, _________________, Philippines, after having been
duly sworn to in accordance with the law, depose, and state that:

I, ____________________ is the surviving spouse of the deceased___________________ who

died on ________________ at ________________________.

That we, _____________________, _____________________, _____________________, and

____________________, are the only children of ____________________ and
__________________.

That we are executing this affidavit to attest to the truth and veracity of the foregoing facts
and for all legal intents and purpose that it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands ___ day of ________________, 20
___ at ______________.

_________________________________________________

Affiant

(State birthday and relationship to the deceased)

 _________________________________________________

Affiant

(State birthday and relationship to the deceased)

_________________________________________________

Affiant

(State birthday and relationship to the deceased)

_________________________________________________

Affiant

(State birthday and relationship to the deceased)

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________
affiant exhibited to his/her competent evidence of identity by way of _________________
issued on __________________ in _______________, Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;