Affdavit of Self-Adjudication of Surviving Spouse

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REPUBLIC OF THE PHILIPPINES

Province of ______________) S.S.


City of ___________)

AFFIDAVIT OF SELF-ADJUDICATION

I, ___________________, of legal age, Filipino, widow/widower and


a resident of ____________________________________, after having been
duly sworn to in accordance with law, depose and state:

1. That I am the widower of _______________, who died intestate in


the City of _____________________________, on
_______________, respectively, as evidenced by the Death
Certificate issued by the ______________________________ hereto
attached as Annex “A” and “B” and made an integral part of
this Affidavit;

2. That at the time of his/her death, my husband/wife had no debts,


liabilities or obligations to any persons, agency or institution;

3. That my afore-named deceased husband/wife left


________________________________________________;

4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby


adjudicate unto myself the said
____________________________________, which represents my
lawful inheritance, and hereby files the same with the
______________________________ with the request that said
adjudication be made effective without judicial proceedings as
prescribed by the aforementioned Rules of Court;

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day


of ___________ ____ in ________ City, Province of
______________,Philippines.

__________________
Affiant

SUBCRIBED AND SWORN TO before me this ____ day of


____________ _____ in ___________ City, Province of
______________, Philippines, affiant exhibiting to me his
______________________.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 20___.

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