REPUBLIC OF THE PHILIPPINES) PROVINCE OF AAA MUNICIPALITY OF BBB ) S.S.

) AFFIDAVIT OF SELF-ADJUDICATION I, ABC, of legal age, Filipino, single and a resident of No. 123 Municipality of AAA, Province of BBB, Philippines, after having been duly sworn in accordance with law, do hereby depose and say:

1. That I am the only daughter of X who died intestate ini the Municipality of AAA, Province of BBB, on April 08, 2002 as evidenced by Death Certificate issued by the Municipality of AAA, Province of BBB, hereto attached as ANNEX A and made an integral part of this Affidavit;

2. That the said deceased left deposit in the Rural Bank of AAA, Inc., in the amount of P300,000;

3. That the said deceased left no debts;

4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate unto myself the above described real estate by means of this Affidavit and hereby files the same with the Register of Deed of BBB with the request that the said adjudication be made effective without judicial proceeding as prescribed by the aforementioned Rules of Court. IN WITNESS WHEREOF, I have set my hand this _____ day of ____________ 2011 at Municipality of AAA, Province of BBB, Philippines.

ABC Affiant SUBSCRIBED AND SWORN before me this ____ day of ____________ 2011 at Municipality of AAA, Province of BBB, Philippines.

CCC Notary Public Commission to expire:______ IBP No., Place, Date PTR No., Place, Date

Doc. No.______; Page No. _____ ; Book No. _____ ; Series of ______