REPUBLIC OF THE PHILIPPINES )

CITY OF ______________________ ) S.S.

AFFIDAVIT OF SELF-ADJUDICATION

I, [full name] , of legal age, Filipino, [civil status] and a resident of [address]
after having been duly sworn to in accordance with law, depose and state:

1. That I am the [state capacity as legal heir, i.e., only child/widow/remaining

parent] of [name of deceased] (Deceased) who died without any last will and
testament on [date] in [City, Province] as evidenced by his/her Death
Certificate issued by the City of [specify] hereto attached as Annex “A” and
made an integral part of this Affidavit;

2. That at the time his/her death, the Deceased had no debts, liabilities or
obligations to any persons, agency or institution;

3. That the only property/ies left by the Deceased are:

[state nature and description of properties]

[attach supporting documents as Annexes]

4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate
unto myself the above-described Property/ies by means of this Affidavit and
hereby files the same with theRegister of Deed of [specify] City 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

[month] [year] in [specify] City, [Province], Philippines.

[name and signature]

Affiant
 SUBSCRIBED and SWORN to before me, in the City of Davao, this
th
11 day of December, 2019 by the affiant ALFRED GENE LACANDULA
with Passport Number. 1645789 valid until December 5, 2021 issued at Davao
City, Philippines on July 20, 2018.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2020;