REPUBLIC OF THE PHILIPPINES]

PROVINCE OF DAVAO DEL SUR]

CITY OF DIGOS ] S.S.
X---------------------------------------X

AFFIDAVIT OF SELF-ADJUDICATION

I, JUAN DE LA CRUZ, of legal age, Filipino, single and a

resident of 3881 R. Magsaysay St., Zone 3, Poblacion, Digos
City, Davao del Sur, Philippines, after having been duly
sworn to in accordance with law, do hereby depose and say:

That I am the same and identical person who caused for

the execution of this affidavit;

That I am the only surviving heir, I being the sister, of

the late BEATRIZ J. SIATAN who died on August 5, 2012 at
Medical Center of Digos Cooperative, Digos City, Davao del
Sur;

That my sister, BEATRIZ J. SIATAN, is a member of the

Government Service Insurance System;

That upon her death, she has a remaining GSIS burial

fee in the amount of P 12, 718.8 which is to be taken at
Union Bank, Davao City Branch;

That pursuant to the provision of Section I, Rule 74 of

the Rules of Court, I do hereby settle, adjudicate the above
described GSIS burial fee of the decedent, subject however
to the liabilities imposed under section 4, Rule 74, of the
Rules of Court in favor of any heir or creditor who might have
been unlawfully deprived of his or her lawful participation in
the above estate for a period of two (2) years;

That I am executing this affidavit in order to attest the

truth of the foregoing statements and to apprise the proper
authorities of the same and for whatever legal purposes it
may serve best;

Further affiant sayeth naught.

In witness whereof, I have hereunto set my hand this 9 th

of January 2017 at Digos City, Davao del Sur, Philippines.

JUAN DELA CRUZ

Heir/Affiant
 ID Number 12345

Subscribed and sworn to before me on this this 9 th of

January 2017 at Digos City, Davao del Sur, Philippines,
affiant exhibited to me her Valid Identification No. as above
indicated.

JAMES L. DECOLONGON
Notary Public
Doc No. ____ Until December 31, 2017
Page No. ____ Roll No.: 82714
Book No. ____ IBP No. 631820, January 6, 2014, Digos
City
Series of 2017 PTR No.080324 January 6, 2014 Digos
City TIN: 290-937-407 January
6, 2010 Digos City