REPUBLIC OF THE PHILIPPINES )

PROVINCE OF AAA ) S.S.

MUNICIPALITY OF BBB )

AFFIDAVIT OF ADJUDICATION

I, ABC, of legal age, Filipino, single and a resident of No. 123 Municipality of AAA,
Province of BBB, Philippines, after having been duly sworn in accordance with law, do hereby
depose and say:
1. That I am the only daughter of X who died intestate ini the Municipality of
AAA, Province of BBB, on April 08, 2002 as evidenced by Death Certificate
issued by the Municipality of AAA, Province of BBB, hereto attached as
ANNEX “A” and made an integral part of this Affidavit;

2. That the said deceased left deposit in the Rural Bank of AAA, Inc., in the
amount of P300,000;

3. That the said deceased left no debts;

4. 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 the same with the Register of Deed of BBB with the request that the said
adjudication be made effective without judicial proceeding as prescribed by the
aforementioned Rules of Court.

IN WITNESS WHEREOF, I have set my hand this _____ day of ____________ 2011 at
Municipality of AAA, Province of BBB, Philippines.

ABC
Affiant

SUBSCRIBED AND SWORN before me this ____ day of ____________ 2011 at

Municipality of AAA, Province of BBB, Philippines.

CCC
Notary Public
Commission to expire:______
IBP No., Place, Date
PTR No.,Place, Date
Doc. No.________
Page No. _____
Nook No. ________
Series of _________