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
SUBCRIBED AND SWORN TO before me this ___ th day of [month] [year] in
specify] City, [Province], Philippines, affiant exhibiting to me his/her [competent
evidence of identity] issued in [place of issue] on [date of issue].
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of 20___.