REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _______________ ) SS
MUNICIPALITY OF ___________ )

AFFIDAVIT
I, ________________, a Filipino citizen, of legal age, single/married to
_________________, and residing at _______________________, having been sworn in
accordance with law, depose and say:
That on ____________, 200__, Mr. ____________________ of legal age,
Filipino, single/married to ___________________ residing at ___________________,
sold to me a certain parcel of land under pacto de retro, executed before Notary Public
____________ and bearing Not. Reg. No. ____________ Page ____________, Book
_____________, Series of 200_ of his Notarial Register.
That a copy a true copy of the said pacto de retro sale is hereto attached as
ANNEX A;
That pursuant to said deed of sale with pacto de retro, the said vendor
______________, should have exercised his right to repurchase the said property within
the period of _________________ years;
That the said period expires on ______________________;
That the said vendor, ___________________, by himself or by any other person
in his behalf, has not complied with the condition and stipulation required for the
repurchase of the said property;
That the said period or repurchase has not been extended, either expressly or
impliedly, by affiant vendee a retro;
That by virtue of the said deed of sale with pacto de retro, and by the failure of the
vendor, __________________ to duly repurchase the property therein mentioned within
the period stipulated, there was consolidated in the affiant, as vendee a retro, the absolute
ownership of the said property;
That attached hereto, as ANNEX B, is an order of the Court of First Instance of
_______________ issued on _________________, approving and confirming the above
consolidation of ownership in the name of the affiant.
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of
_________________, 200__, in the Municipality of _______________, Province of
________________, Philippines.

(Signature over Printed Name)

Affiant
SUBSCRIBED and sworn to before me, in the city/municipality of
_______________, this _______ day of _____________, 200_ by ____________ with
Community Tax Certificate No. _________________ issued at ________________ on
__________, 200_.

NOTARY PUBLIC
My commission expires on Dec. 31, 200_

Doc No. ______;

Page No. ______;
Book No. ______;
Series of 200__.