AFFIDAVIT OF SELF-ADJUDICATION

KNOW ALL MEN BY THESE PRESENTS:

I, _____________________, single, of legal age, Filipino Citizen, and a

resident of______________________, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That __________________, died on ______________ at _________________

where he/she last reside and was buried;

2. That at the time of his/her death, he/she left as his/her estate a

parcel of land, more particularly described as follows:

TRANSFER CERTIFICATE OF TITLE NO.__________

A parcel of land (Plan __________), situated in __________________________.

Bounded on the NE., by a property of _________________; and on the SW., by
the Provincial Road and property of_________________. x x x containing an area
of ______________ SQUARE METERS, more or less.

3. That the said deceased left no will, no claims against their estate
and survived by the undersigned lawfully daughter and only
surviving heir;

Now, Therefore, pursuant to Section 1, Rule 74 of the Revised Rules of Court,

I hereby adjudicate unto myself the ownership of that parcel of land above
described.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________________ at _______________________________.

________________________

HEIR
ID No. ___________
 SIGNED IN THE PRESENCE OF:

_________________________ ___________________________
Witness Witness

REPUBLIC OF THE PHILIPPINES)

________________________ ) S.S.

BEFORE ME, this _____________________ at

_______________________________, personally appeared the above-named
parties with her ID No. as above indicated, made known to me to be the
same person who executed the foregoing instrument and she acknowledged
to me that the same is her voluntary act and deed.

Doc. No. _______ ;

Page No. _______ ;
Book No. _______ ;
Series of 2013.