REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

x-------------------------------------x

AFFIDAVIT OF SELF-ADJUDICATION

I, _________________, of legal age, single/married/widow, Filipino citizen, and presently residing at _____________________, after having been duly sworn to in accordance with law, do hereby depose and say:

1. That I am the only daughter of JUAN B. DELA CRUZ who died without any last will and testament on July 20, 2013 in Makati City as evidenced by his Death Certificate issued by the City of Makati hereto attached as Annex “A” and made an integral part of this Affidavit;

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

3. That the only property he left is a parcel of land consisting of 60 square meters located in J.B. Roxas Street, Makati City more particularly described in TCT No. 112233 hereto attached as Annex “B” and made an integral part of this Affidavit;

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 Makati 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 ___________ 20____ in ____________, _____________, Philippines.

___________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________ at ________________ affiant exhibited to his/her competent evidence of identity by way of _________________ issued on __________________ in _______________, Philippines.

Notary Public

Doc. No. ______;

Page No. ______;

Book No. ______;

Series of ______;