REPUBLIC OF THE PHILIPPINES) CITY OF DIPOLOG ) S.S.

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AFFIDAVIT OF SELF-ADJUDICATION
I, _________________, Filipino, of legal age, married and resident of Miputak, Dipolog City, under oath hereby deposeth and sayeth: That I am the only surviving heir of _________, who died intestate in the City of Dipolog on October 27, 2002, without leaving any indebtedness; That said deceased person at the time of her death left the following properties:
1. A parcel of land known as Lot No. 1008-B-2, particularly described as follows: A parcel of land known as Lot No. 1008-B-2, of the subdivision plan (LRC) Psd951528, being a portion of Lot 1008-B, as described on plan Psd-541658, situated in the _________, Municipality of Dipolog, Province of Zamboanga del Norte, containing an area of __________________, more or less, covered by Transfer Certificate of Title No. T-1565158 of the Registry of Deeds of Dipolog City, the exact description of which is indicated on the face of the aforesaid certificate of title. 2. A parcel of land known as Lot No. 105208-B-3, particularly described as follows: A parcel of land known as Lot No. 100518-B-3, of the subdivision plan (LRC) Psd-95524098, being a portion of Lot 1008-B, as described on plan Psd-53678, situated in the Poblacion, Municipality of Dipolog, Province of Zamboanga del Norte, containing an area of ________ (358 SQ.M.), more or less, covered by Transfer Certificate of Title No. T-16786 of the Registry of Deeds of Dipolog City, the exact description of which is indicated on the face of the aforesaid certificate of title. 3. A residential house built on a portion of Lot No. ______, situated at Dipolog City.

That pursuant to the Rules of Court, I, being the only heir of said decedent, do hereby adjudicate unto myself the above-described properties by means of this Affidavit of Self-Adjudication and which is filed with the Office of the Registry of Deeds of Dipolog City, with the request that said adjudication be made effective without judicial proceedings, and that the title of the above-described properties be cancelled, and that new certificates of title be issued in my name; That this Affidavit of Self-Adjudication is published in the Dipolog Chronicle for three (3) consecutive weeks. IN WITNESS WHEREOF, I hereunto affix __________________, 2004 at Dipolog City, Philippines. my signature this

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Affiant SUBSCRIBED AND SWORN to before me, this ________________________, 2004, in the City of Dipolog, affiant exhibiting his Community Tax Certificate No. _____________, issued on _______________, at ____________________________.

Doc. No. _____: Page No._____:

Notary Public

Book No.______ Series of 2004.

Until December 31, 2005 PTR No. 44325127 01-14-04 IBP No. 605510 01-08-04 ____ City