REPUBLIC OF THE PHILIPPINES)

_________________________) S.S.
x-------------------------------------x
AFFIDAVIT OF SELF-ADJUDICATION
I, ____________, of legal age, Filipino, single and a resident of
__________________, after having been duly sworn to in accordance with
law, depose and state:
1. That I am the only son/daughter of ____________ who died without any
last will and testament on _________ in __________ as evidenced by his
Death Certificate issued by the __________ hereto attached as Annex A
and made an integral part of this Affidavit;
2. That at the time his death, my father had no debts, liabilities or
obligations to any persons, agency or institution;
3. That the only properties he left are:
a.
a parcel of land consisting of 60 square meters located in
___________ more particularly described in TCT No. ___________
hereto attached as Annex B and made an integral part of this Affidavit;
b. ___ (no.) of shares of stock of ________________ with a par value
of ___________; and
4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate
unto myself the above-described real estate and shares of stocks by means
of this Affidavit and hereby files the same with the Register of Deed of
_________ with the request that the said adjudication be made effective
without judicial proceeding as prescribed by the aforementioned provision of
the Rules of Court.
IN WITNESS WHEREOF, I have hereunto set my hand this ____ day
of __________ 2015 in ___________.

_________________
Affiant