REPUBLIC OF THE PHILIPPINES)

QUEZON CITY_____________) S.S

AFFIDAVIT OF SELF-ADJUDICATION BY SOLE HEIR

I, (Name of Sole Heir), Filipino, of legal age, (Civil Status), with residence address at
_____________, under oath, depose/s and say:

1. That I am the surviving (wife/husband/daughter/son/sister/brother/relative etc.) and only

sole heir of the late (Name of the Deceased), there being no other ascendants,
descendants or collateral relatives, surviving, who died intestate in (Place of Death) last
(Date of Death);

2. That at the time of (his/her) death, (he/she) left a parcel of land covered by Transfer
Certificate of Title No. ______, issued by Register of Deeds for (City/Municipality),
with an area of _________ SQUARE METERS, more or less, located in the City of
_______, Philippines, particularly described as follows:

(ORIGINAL/TRANSFER) CERTIFICATE OF TITLE NO._______

A parcel of land (Lot 7-B, of the subdivision plan Psd-00-054674, being a portion of Lot 7,
Block 5, (LRC) Psd-47385, LRC Record No 5975), situated in Brgy. Talipapa, Quezon
City, Metro Manila, Island of Luzon. Bounded on the NW., along lines 1-2-3, by Road Lot 2
(LRC) Psd-47385 (12.00 m. wide), on the NE., and SE., along lines 3-4-5, by Lot 7-A, of
the subdivision plan, and on the SW., along line 5-1, by Lot 6, Block 5, (LRC) Psd-47385.
Beginning at a point marked “1” on plan, being S. 80 deg. 02’W., 481.82 m, from LM No.
18, Piedad Estate,

thence N. 40 deg. 16’e., 5.00 m. to point 2;

thence N. 58 deg. 16’E., 4.77 m. to point 3;
thence S. 31 deg. 26’E., 12.20 m. to point 4;
thence S. 57 deg. 17’W., 6.03 m. to point 5;
thence N. 49 deg. 27’W., 11.29 m. to the point of beginning; containing
an area of NINTY FOUR (94) SQUARE METERS, more or less. All points referred to are
indicated on the plan and are marked on the ground by PS cyl. conc. mons. 15x40 cm.,
except points 1 & 2, by Old PS cyl. conc. mons. 15x60 cm., bearings true, date of original
survey, July 1-Dec. 14, 1970 (Piedad Estate), that of the subdivision survey, April 15,
2000, and was approved on June 15, 2000.

3. That the deceased left no debts or obligation;

4. That the above-mentioned deceased died intestate, without leaving a will;

5. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate unto myself
the above-described parcel of land including all improvements built thereon by means of this
 affidavit and hereby files the same with the Register of Deeds for the City/Municipality of
_____ and other concern agencies with the request that the said adjudication be made
effective without judicial proceedings as prescribed by the aforementioned Rules of Court;

6. I am executing this instrument, to attest to the foregoing facts and circumstances and for
all legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have set my hand this ___day of _____, 20__ in the City of
_______, Philippines.

________________________
Affiant
Passport Number _______
Valid Until ___________
Issued At Canada

SUBSCRIBED AND SWORN TO BEFORE ME a notary public for and in the City of _____ this
____day of ____, 201___ by the affiant who personally appeared before me and identified by
me through a competent evidence of her identity bearing specimens of her photograph and
signature. The material details of which are written immediately below her name.

Doc. No. _____

Page No._____
Book No._____
Series of 20__