AFFIDAVIT OF SURVIVING LEGAL HEIRS

We ____________________, ____________________, ____________________, of legal age,

____________________, ____________________, Filipino and resident of ________________,
_______________, ________________, _________________, Philippines, after having been duly sworn
to in accordance with the law, depose, and state that:

I, ____________________ is the surviving spouse of the deceased___________________ who died

on ________________ at ________________________.

That we, _____________________, _____________________, _____________________, and

____________________, are the only children of ____________________ and __________________.

That we are executing this affidavit to attest to the truth and veracity of the foregoing facts and
for all legal intents and purpose that it may serve.

IN WITNESS WHEREOF, we have hereunto set our hands ___ day of ________________, 20 ___ at
______________.

___________________ ____________________
Affiant Affiant
(State birthday and relationship to the deceased) (State birthday and relationship to the deceased)

____________________ _____________________
Affiant Affiant
(State birthday and relationship to the deceased) (State birthday and relationship to the deceased)

____________________
Affiant
(State birthday and relationship to the deceased)

SUBSCRIBE AND SWORN to me before this ____ day of ___________, at ______________ on

_________, affiant exhibited to me his/her Government issued ID __________No._________________
issued at __________ on ____________.

Doc. No. _________

Page No. _________
Book No. _________
Series of _________ NOTARY PUBLIC