Republic of the Philippines)
Province of ____________________)S.S.
City/Municipality of _____________)
x – – – – – – – – – – – – – – x
I, _____________, Filipino, of legal age, (single / married / widow), and a resident of _____________, Philippines, after being sworn in accordance with law, depose and state:
1. That I am the only child and sole heir of _____________ who died intestate on _____________ at _____________;
2. That said deceased left a certain parcel of land covered by Transfer Certificate of Title No. _____________ and more particularly described as follows:
(Technical Description of Property)
3.That said deceased left no debts, nor any Last Will and Testament;
4.That pursuant to Sec. 1 of Rule 74 of the Revised Rules of Court of the Philippines, I hereby adjudicate unto myself the above-described parcel of land, and the improvements found and standing thereon, and I hereby request the Register of Deeds to issue a new Transfer Certificate of Title in my name;
5.That the above-described parcel of land does not come under the operation of the Comprehensive Agrarian Reform Program.
IN WITNESS WHEREOF, I have hereunto set my hand this _____________ in _____________, Philippines.