REPUBLIC OF THE PHILIPPINES ) PROVINCE OF _______________ ) SS MUNICIPALITY OF ___________ )

AFFIDAVIT
I, of legal age, single/married to __________________ and now residing at _________________, Philippines, after having been sworn in accordance with law, depose and say: 1. That I am the only surviving son of one, named ________________ who died intestate in the municipality of __________________, Philippines, on _______________ as evidenced by Death Certificate issued by the _____________ hereto attached as ANNEX A and made an integral part of this Affidavit; 2. That said deceased left an estate consisting of a parcel of land measuring _______________ sq. m., located in the municipality of ________________, and evidenced by Transfer of Title No. _________________ of the Registry of Deeds of ________________; 3. That the said parcel of land is more particularly described as follows, to wit: TTRANSFER CERTIFICATE OF TITLE NO. T-_______ TECHNICAL DESCRIPTIONS LOT ______ "A PARCEL OF LAND (Lot ____, ____________), situated in the _________________. Bounded on the ____________________________. Beginning at a point marked "1" on plan, being ________________; point of beginning containing an area of _________________ (_____) SQUARE METERS, more or less. All points referred to are indicated on plan and are marked on the ground as follows:_____________." 4. That said deceased left no debts; 5. That the net value of said estate is not more than three thousand pesos (P3,000.00), and is therefore exempt from the estate and inheritance taxes, as evidenced by a certificate of exemption issued by the Bureau of Internal Revenue hereto attached as ANNEX B and made an integral part of this affidavit; 6. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate unto myself the above described real estate by means of this Affidavit and hereby files same with the Register of Deeds of ____________ with the request that said adjudication

be made effective without judicial proceedings as prescribed by the aforementioned Rules of Court. IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of ___________________, 200_ in _________________, 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__.