AFFIDAVIT OF SELF – ADJUDICATION

Republic of the Philippines)

Province of _________________ ) S. S.
Municipality of ________________

I ________________________________, of legal age,Filipino citizen, married and with residence at

______________________________________, after having been sworn in accordance with law, hereby
depose and say:

That I am the sole and only surviving legal heir of the late ____________________________ who died
__________years ago at Infanta, Pangasinan, leaving without any will or debt that has not been settled
up to the present.

That said deceased at the time of his death left a parcel of land/residential lot situated at
Poblacion,Infanta, Pangasinan, which is more particularly described to wit :

“ A parcel of land, situated at Poblacion, Infanta, Pangasinan, designated as lot no._______,

containing an area of ____________________________square meters,
Bounded on the North by _______________________________:on the East by ____________________
________________: on the North by _________________________________________:on the south by
__________________________________..covered by ARP/Tax Declaration No. ___________________
Declared in the name of ___________________________________, with an assessed value of P
-------------------------------------------------.

That pursuant to Sec. 1 Rule 74 of the Revised Rules of Court of the Philippines, I hereby Adjudicate
unto myself the above described parcel of land without judicial proceedings as prescribed by the
aforementioned Rules of Court.

That for and in consideration of the sum of THREE MILLION PESOS (P3,000,000.00) Philippine
currency, in hand paid by _______________________________ of legal age,Filipino citizen and a
resident of __________________________________________, receipt of which is hereby
Acknowledged to my great satisfaction , do hereby these presents SELL, CEDE, TRANSFER and
CONVEY absolute unto the said person _________________________________, their heirs,
Successors, and assigns said parcel of land above described.

IN WITNESS WHEREOF, I have here unto set my hand this _______day of __________, 2019, at
___________________________________.

______________________________________
Affiant

Page 1 of 2
SIGNED IN THE PRESENCE OF

1. ____________________________________ 2. _____________________________________

SUBSCRIBED AND SWORN to before me this _______day of ______________ 2019, at ______________

_______________________________ by ______________________________ with his valid CTC No.
___________________________ issued on_________________________ 2019, at _______________
_____________________________as proof of his identification.

_______________________________________
Notary Public
Doc. No. _____________
Page No. _____________
Book No. _____________
Series of _____________