Download - Legal Forms (Midterms)

LEGAL FORMS

Under ATTY. LAZO Sunday Class (3:00 - 5:00 pm) Compiled by: EUNICE R. TABINAS ARELLANO UNIVERSITY SCHOOL OF LAW

JURAT vs. ACKNOWLEDGMENT

JURAT

SUBSCRIBED AND SWORN TO before me in the City of _______________ on this day of _________________, affiant exhibiting before me his Government Issued ID no. _______________ issued on __________________ at _____________________.

(Sgd.) N. O. TARIO Notary Public

Until __________________ PTR No. _______________ Issued at ______________ On ___________________

Doc. No. Page No. Book No. Series of 2007.

ACKNOWLEDGMENT

Republic of the Philippines ) City of Manila ) s.s. BEFORE ME, this 13th day of April, 2007 in the City of Manila, Philippines, personally appeared ATTICUS FINCH, with [Valid Identification Document] (Driver’s License No. N25-07-007777) issued by the [official agency] (Land Transportation Office) on 10 January 2007, known to me to be the same person who executed the foregoing instrument, and who acknowledged to me that the same is his free act and deed. IN WITNESS WHEREOF, I have set my hand and affixed my Notarial seal on the day, year and place written.

(Sgd.) N. O. TARIO Notary Public

Until __________________ PTR No. _______________ Issued at ______________ On ___________________

Doc. No. Page No. Book No. Series of 2007

LEGAL FORMS under ATTY. LAZO Compiled By: EUNICE R. TABINAS Sunday (3-5 pm) Arellano University School of Law

NOTE: If the instrument consists of 2 or more pages, include the following after the 1st paragraph: This instrument, consisting of ___ pages, including the page on which this acknowledgment is written, has been signed on the left margin of each and every page thereof by ___________ and his witnesses (if any), and sealed with my Notarial Seal. NOTE: If the instrument conveys 2 or more parcels of land, include the following after the 1st paragraph: This instrument relates to the sale (or mortgage) of ___ parcels of land, and consists of ___ pages including the page on which this acknowledgment is written, each and every page of which, on the left margin, having been signed by ______________ and his witnesses (if any), and sealed with my Notarial seal.

SAMPLE LEGAL FORMS

AFFIDAVIT OF LOSS

PAWNSHOP TICKET REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF _____ ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident of _______________________________, after

having been duly sworn to in accordance with law, depose and state THAT:

1. Sometime on ______________, I pawned my _________ with Tambunting Pawnshop located at

_____________________ and for which I was issued Pawn Ticket/Receipt No. _________;

2. I kept the said pawn ticket in my wallet for safekeeping but unfortunately my wallet got lost;

3. Despite diligent search and efforts to locate the said wallet and pawn ticket, I could not find the

same such that I believe that they are now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to enable me to secure a

duplicate or substitute copy of the ticket and/or redeem the above-described item which I pawned.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in

____________, Philippines.


____________________

Affiant

GSIS ID No. _____________

SUBCRIBED AND SWORN TO before me this ___________________ in _________________, Philippines, affiant

exhibiting to me his valid proof of identification.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2013.

DRIVER’S LICENSE

REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, (single/married/widow) and a resident of

_______________________________, after having been duly sworn to in accordance with law, depose and

state THAT:

1. I am a duly-licensed driver in accordance with pertinent Land Transportation laws, rules and

regulations, and was issued a corresponding (Non) Professional Driver's License with number

_____________ which is valid until _____________;

2. Sometime on ____________, said driver's license was misplaced and got lost;

3. Efforts were exerted to locate said driver's license, but in spite of diligent search, it could not be

found and the same is now beyond recovery;

4. Said Driver's License has not been confiscated by the LTO, Police or other Traffic Enforcers for any

traffic violation;

5. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to support

my application for the issuance of a new (Non) Professional Driver's License, in lieu of the one that

was lost;

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati City,

Metro Manila, Philippines.


____________________

Affiant

SSS ID No. _____________


exhibiting to me his/her competent evidence of identity by way of __________________ issued at

______________ on __________________.

Doc. No. _____;

Page No. _____;

Book No. _____; Series of 2013.

PASSPORT

REPUBLIC OF THE PHILIPPINES)

CITY OF MAKATI ) S.S.

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

AFFIDAVIT OF LOSS

I, ___________________, of legal age, Filipino, single and a resident of _______________________________, after

having been duly sworn to in accordance with law, depose and state THAT:

1. On January 12, 2010, I was issued a Philippine Passport by the Department of Affairs in Manila;

2. Recently, I had tried to look for the said passport but the same could not be found;

3. Despite diligent search and efforts to locate the said passport, I could not find the same such that I

believe that it is now lost beyond recovery;

4. As such, I am executing this affidavit to attest to the foregoing facts and to support the application

for the issuance of a new one in lieu of the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ___________________ in Makati City,

Metro Manila, Philippines.

____________________

Affiant

GSIS ID No. _____________


exhibiting to me his valid proof of identification.


Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2013.

PETITION FOR NOTARIAL COMMISSION

Republic of the Philippines

REGIONAL TRIAL COURT OF CEBU 7th Judicial Region

OFFICE OF THE EXECUTIVE JUDGE Cebu City

IN THE MATTER OF THE PETITION FOR RENEWAL OF COMMISSION AS NOTARY PUBLIC FOR THE CITY OF CEBU AND CITIES/MUNICIPALITIES OF THE PROVINCE OF CEBU UNDER THE TERRITORIAL JURISDICTION OF THIS HONORABLE COURT Notarial Commission No. : __________

MAGDALENA M. R. LEPITEN Petitioner. x----------------------------------------x

P E T I T I O N

PETITIONER, MAGDALENA M. R. LEPITEN to this Honorable Court, most respectfully files this

petition/application for renewal of her Commission as a Notary Public for the province and in the City

of Cebu, for a term commencing on Jan. 1, 2012 and ending on Dec. 31, 2013. In support of this petition,

she states, that:

1. 1. She was previously granted a Notarial Commission by Order dated Nov. 25, 2009 signed by

then Executive Judge Meinrado Paredes . Attached is a copy of the Order marked as Annex “A.”

2. 2. She possesses the eligibility for commissioning as Notary Public as shown by her following


personal circumstances:

a. Nationality : Filipino

b. Date/ Place of Birth : July 22,1961/ Tacloban City

c. Residence : 33 Dapdap St., Mambaling, Cebu City

d. Telephone No. : 2548005

e. PTR Number : 875649 January 6, 2011, Cebu City

f. Roll of Attorney No. : 36617, April 11, 1990

g. IBP Number : 567022 Lifetime Cebu City

3. She has satisfactorily completed the required course in law at the Manuel L. Quezon

University, Manila on April 10, 1989; passed the Bar Examinations of September, 1989 and

admitted to the practice of law in April 11, 1990;

4. She holds office at the following address:

LEPITEN & BOJOS LAW OFFICE 21-F Don Pedro Rodriguez St., Capitol Site, Cebu City 6000 Philippines

5. That she is a resident of the Philippines since birth;

6. She has not been convicted, much less, charged with any offense involving moral turpitude;

7. She is a member of good standing of the Philippine Bar as shown by the following certification: a. Certification of No Pending Administrative Case issued by the Bar Confidant’s Office of the Supreme Court, Manila (Annex “B”), b. Certification of No Criminal Case filed against her issued by the Office of the Clerk of Court, Regional Trial Court, Cebu City (Annex “C”).

c. Certification as a Member of Good Standing issued by the IBP-Cebu Province Chapter (Annex “D”).

8. Three of her identification pictures with corresponding signatures at the bottom are

attached in this petition;

9. She has not applied for nor was she issued a Commission as a Notary Public in any other


jurisdiction for the current year;

10. Attached hereto is a separate sheet of paper and forms part of this petition containing three

(3) specimens of petitioner’s signature.

11. She undertakes to submit or report to the Office of the Clerk of Court copies of all deeds

notarized by her.

12. SUBMITTED. Dec. 2, 2011, Cebu City, Philippines.

ATTY. MAGDALENA R. LEPITEN Petitioner LEPITEN AND BOJOS LAW OFFICE

21-F Don Pedro Rodriguez St., Capitol Site, Cebu City, Philippines Roll No. 36617 MCLE Compliance No.: III-0007418 PTR No 875649 January 6, 2011, Cebu City IBP No. 567022 Lifetime

VERIFICATION

I, MAGDALENA M.R. LEPITEN, Filipino, of legal age, married and a resident of 33 Dapdap St., Mambaling, Cebu City, after being duly sworn to in accordance with law hereby state:

1. That I am the petitioner of the above instant case.

2. That I have caused the preparation of the above-entitled petition.

3. That I have read the same and that it is true and correct based on my personal knowledge or

based on authentic records.

4. That I hereby certify under oath in this petition as follows:

a. I have not theretofore commenced any action or filed any action or claim involving the same issue in any court, tribunal or quasi-judicial agency and, to the best of my knowledge, no such other pending action or claim is pending therein;

b. If there is such other pending action or claim, a complete statement of the present status

thereof; and

c. If I should thereafter learn that the same or similar action or claim has been filed or is pending, I shall report that fact within five (5) days therefrom to the court wherein the aforesaid


complaint or initiatory pleading has been filed. IN WITNESS WHEREOF, I have hereunto affixed my signature this , Cebu City, Philippines.

ATTY. MAGDALENA M.R LEPITEN CTC No.:11385970 Issued on Jan. 4, 2010 Issued at Cebu City

SUSBCRIBED AND SWORN TO before me, a notary in the Province and City of Cebu, personally appeared above name with hers Community Tax Certificate Number as shown above, who is personally known to me to be the same and/ or identified through competent evidence of identity as defined by Rules on Notarial Practice, who presented the foregoing instrument and signed the instrument in my presence, and who took an oath before me as to such instrument.

Witness my hand and seal this Dec. 2, 2011

Doc. No. Page No.

Book no. Series of

PETITIONER MAGDALENA M.R. LEPITEN SPECIMEN SIGNATURE

__________________________

__________________________

___________________________

THREE PASSPORT SIZE COLOR PHOTOGRAPHS

SIGNED AT THE BOTTOM BY PETITIONER

DEED OF SALE

REGISTERED LAND

Republic of the Philippines ) Makati City ) s.s.

DEED OF ABSOLUTE SALE KNOW ALL MEN BY THESE PRESENTS: I, MA YA MAN, Filipino, single, and resident of _________________________, for and in consideration of the amount of _______________________, paid to me today by MA GU LANG, Filipino, single and resident


of ________________ do hereby SELL, TRANSFER and CONVEY absolute and unconditionally unto said MA GU LANG that certain parcel(s) of land, together with the buildings and improvements thereon situated in the City of Makati, and more particularly described as follows:

(Technical Description of property/ies; specify metes and bounds of the property/ies with approximate area thereof, as indicated on the face of the title)

of which I am the registered owner in fee simple, my title thereto being evidenced by Transfer (or Original) Certificate of Title No. ______, issued by the Register of Deeds of Makati City. It is hereby mutually agreed that the vendee shall bear all expenses for the execution and registration of this deed of sale. IN WITNESS WHEREOF, I have signed this deed this 7th day of July, 2007 at Makati City.

MA YA MAN Vendor

[Note: if vendor is married, marital consent must be secured; thus, the Deed must also indicate this. If vendor is married, then add the following:]

With my consent:

ASA WA Vendor’s Wife

SIGNED IN THE PRESENCE OF:

(Sgd.) MIRON 1

(Sgd.) MIRON 2

PLUS: Acknowledgment

UNREGISTERED LAND Republic of the Philippines ) Makati City ) s.s.

DEED OF ABSOLUTE SALE KNOW ALL MEN BY THESE PRESENTS: I, MA YA MAN, Filipino, single, and resident of _________________________, for and in consideration of the amount of __________, paid to me today by MA GU LANG, Filipino, single and resident of _______________________ do hereby SELL, TRANSFER and CONVEY absolutely and unconditionally unto said MA GU LANG that certain parcel(s) of land, together with the buildings and improvements thereon situated in the City of Makati, and more particularly described as follows:

(Description: state the nature of each piece of land and its improvements, situations and boundaries, area in square meters, whether or not the boundaries are visible on the


land by means of monuments or otherwise; and if they are, what they consist of, the permanent improvements, if any, the page number of the assessment of each property for current year or years when registration is made, the assessed value of the property for the year)

It is hereby declared that the boundaries of the foregoing land are visible by means of _______________; that the permanent improvements existing thereon consist of _________ (if none, state so); that the land is assessed for the current year at P______________ as per Tax Declaration No. __________, and the buildings and/or improvements , at P____________ as per Tax Declaration No. _________, of the City Assessor of Makati. The above described real estate, not having been registered under Act No. 496 nor under the Spanish Mortgage Law, the parties hereto have agreed to register this instrument under the provisions of Sec. 194 of the Revised Administrative Code, as amended. IN WITNESS WHEREOF, I have signed this deed this 7th day of July, 2007 at Makati City.

MA YA MAN Vendor

[Note: if vendor is married, marital consent must be secured; thus, the Deed must also indicate this. If vendor is married, then add the following:]

With my consent:

ASA WA Vendor’s Wife


(Sgd.) MIRON 1

(Sgd.) MIRON 2


PARCEL OF LAND Republic of the Philippines ) Makati City ) s.s.

DEED OF SALE WITH PACTO DE RETRO This Deed of Sale with Pacto de Retro made and executed by and between:

MA YA MAN, Filipino, of legal age, married to ASA WA, with residence at ___________________ (VENDOR),

- and -


MA GU LANG, Filipino, of legal age, married to BA TAPA, with residence at ____________ (VENDEE);

WITNESSETH: That–

The VENDOR is the absolute owner of a certain parcel of land with all the buildings and improvements thereon, situated in the City of Makati, and more particularly described, as follows:

(Copy technical description in TCT/OCT) his title thereto shown by Transfer (or Original) Certificate of Title No. ______ issued by the Register of Deeds of Makati; The VENDOR, for and in consideration of the amount of _________________ Pesos (P_____), to him paid by VENDEE and receipt of which is acknowledged, does hereby SELL, TRANSFER and CONVEY under pacto de retro unto the said VENDEE, his heirs and assigns, the property with all the buildings and improvements thereon, free from all liens and encumbrances whatsoever; The VENDOR, in executing this conveyance, hereby reserves the right to REPURCHASE, and the VENDEE, in accepting the same, hereby obligates himself to RESELL the property herein conveyed within a period of ____ years from date of this deed for the same price of ______________ (P____); Provided, however, that if the VENDOR shall fail to exercise his right to repurchase as herein granted within the period provided, then this conveyance shall become absolute and irrevocable, without need of a new Deed of Absolute Sale, subject to the requirements of law regarding consolidation of ownership of real property. IN WITNESS WHEREOF, I have signed this deed this 7th day of July, 2007 at Makati City.

MA YA MAN MA GU LANG Vendor Vendee

With my marital consent: With my marital consent: ASA WA BA TAPA


(Sgd.) MIRON 1

(Sgd.) MIRON 2



AFFIDAVIT OF SERVICE

Republic of the Philippines)

Province of ____________________)S.S.

City/Municipality of _____________)

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

AFFIDAVIT OF SERVICE

I, _____________, of legal age, (single / married / widow), and a resident of _____________, Philippines, after

having been duly sworn in accordance with law, hereby depose and say:

That I am a Secretary / Legal Aide of the law office of Atty. _____________ with office address at

_____________, Philippines;

That in my aforementioned capacity, I had personally served a copy of the _____________ in the case

entitled "_____________," docketed as _____________ Case no. _____________ (by personal service) to the office

of _____________'s Counsel of Record, ATTY. _____________, with address at _____________ (by registered mail

with return card under Registry Receipt No. _________).

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________, Philippines

AFFIANT

(JURAT)

AFFIDAVIT OF DESISTANCE (ESTAFA CASE)

Republic of the Philippines

National Capital Judicial Region

METROPOLITAN TRIAL COURT

Branch LXII (62)

Makati City

PEOPLE OF THE PHILIPPINES,

Plaintiff,

- versus - Crim. Case No. 111222

REY L. MAPA,

Defendant.

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


AFFIDAVIT OF DESISTANCE

I, FERDINAND M. GERON, Filipino, of legal age, married, and with office address at Pure Finance

Corporation, 1234 Chino Roces Avenue, Makati City, after having been duly sworn to in accordance

with law, depose and state:

1. That I am the authorized representative of PURE FINANCE CORPORATION, the private complainant

in Criminal Case No. 111222 against REY L. MAPA for violation of Batas Pambansa Bilang 22

pending before the Metropolitan Trial Court of Makati City, Branch 62 (copy of the Secretary's

Certificate is hereto attached as Annex "A" and form and integral part hereof;

2. That after a careful evaluation of the facts surrounding the case, I came to realize that the case arose

out of misapprehension of facts and that the account of the accused has already been settled even

prior to the filing of this case;

3. That I have decided not to pursue the case against the accused considering that under the

circumstances, it will be extremely difficult for the prosecution to secure conviction of the accused;

4. That because of the foregoing reasons, I am now desisting in the further prosecution of the case and

will no longer testify against the accused.

IN WITNESS WHEREOF, I have hereunto set my hand this 7th day of August 2013 at Makati

City, Philippines.

FERDINAND M. GERON

Affiant

Philippine Passport No. _____

Issued at: ________________

Issued on: _______________

SUBCRIBED AND SWORN TO before me this 7th day of August 2013 at Makati City, Philippines. I

hereby certify that I have examined the affiant personally and that he voluntarily executed his

affidavit and understood the same.

PUBLIC PROSECUTOR

CONTRACT TO SELL (CONDOMINIUM UNIT)

http://nbdcglobal.com/forms/condos/BMHT_NPR-Contract_To_Sell-short.pdf http://www.tagaytaycondominium.com/cts.pdf

http://nbdcglobal.com/forms/condos/BMHT_NPR-Contract_To_Sell-short.pdf

http://www.tagaytaycondominium.com/cts.pdf


EASEMENT OF A RIGHT OF WAY

EASEMENT OF RIGHT OF WAY

KNOW ALL MEN BY THESE PRESENTS:

This AGREEMENT OF EASEMENT OF RIGHT OF WAY, entered into this ______ day of

______________, 2001 by and between “A” owner of the dominant estate, of legal age, single (or married

to ___________________) and a resident of _________________ and “B” , owner of the servient estate, also of

legal age, single (or married to ____________________), and a resident of ________________________ witnesseth:

That “A” is the owner of a parcel of agricultural land located in the municipality of

________________, province of ________________, and more particularly described as follows, to wit:

(Description of “A’s” property)

which property is covered by T.C.T. No. ________ of the Register of Deeds of ______________, province of

_______________, which lot is adjacent to “A’s” property, and more particularly described as follows, to

wit:

(Description of “B’s” property)

which property is covered by T.C.T. No. _____________ of the Register of Deeds of the province of

_____________________.

That “A” in order to have an access to and from, and to cultivate the above-mentioned land, and

so as to have an outlet to ________________, which is the nearest public road and least burdensome to the

servient estate and to third persons, it would be necessary for him to pass through “B’s” property, and

for this purpose, a path or passageway of not less than two (2) meters wide through the whole length

of the western side of “B’s” property is necessary for the use of “A” and for all his needs in cultivating

his estate;

That said path or passageway is particularly described in the attached plan, “Annex A’,

WHEREFORE, for and in consideration of the sum of _____________________ PESOS (P_________) the

receipt whereof is hereby acknowledged by “B”, the latter agrees and permits “A” to have a permanent

easement of right of way over the above-mentioned property of said “B” limited to not more than two

(2) meters wide throughout the whole length of the western side of said property and as specifically

indicated in the attached plan which is made an integral part of this contract, as “Annex A”.

It is further agreed that “B” shall deliver unto “A” all the necessary papers, deed, and titles in

relation to the servient estate in order to facilitate the registration of the above-mentioned right of

way, in accordance with.


This agreement shall be binding between the parties and upon all their heirs, successors, and

assigns.

IN WITNESS WHEREOF, the parties hereto have signed this agreement the day and the year

first above written, in the municipality of _______________, province of _______________, Philippines.

__________________________ __________________________

(Signature of owner of the (Signature of owner of

dominant estate) servient estate)


__________________________ ___________________________

ACKNOWLEDGMENT

EXTRAJUDICIAL SETTLEMENT OF ESTATE

EXTRAJUDICIAL SETTLEMENT OF ESTATE

KNOW ALL MEN BY THESE PRESENTS:

This AGREEMENT made and entered into this 2nd day of October 2013 by and among:

LEILA M. SANTOS, of legal age, Filipino, single, and with residence and postal address at 1111

Santillan Street, Pio del Pilar, Makati City;

MILA M. SANTOS-RUBIO, of legal age, Filipino, married, and with residence and postal address at

2222 J. Victor Street, Pio del Pilar, Makati City:

JOSE M. SANTOS, of legal age, Filipino, single, and with residence and postal address at 3333 Taylo

Street, Pio del Pilar, Makati City;

WITNESSETH:

THAT we are the legitimate children and sole heirs of LUCIO T. SANTOS who died on June 25,

2013 in Makati City; copy of his death certificate is hereto attached as Annex "A";

THAT said deceased died without any will or testament and without any outstanding debts in

favor of any person or entity;


THAT said deceased, at the time of his death, left a certain real property, situated in Makati City and

more particularly described as follows, to wit:

(Technical Description of property; specify metes

and bounds of the property with approximate area

thereof, as indicated on the face of the title)

THAT pursuant to Section 1 of Rule 74 of the Revised Rules of Court of the Philippines, and we

being all of age and with full capacity to contract, we do hereby adjudicate unto ourselves the land

described above, in equal shares.

IN WITNESSS WHEREOF, we have hereunto signed this AGREEMENT, this 2nd day of October

2013 in the City of Makati, Philippines.

THE HEIRS OF LUCIO T. SANTOS

LEILA M. SANTOS MILA M. SANTOS-RUBIO

JOSE M. SANTOS


__________________________ _____________________________

Witness Witness

ACKNOWLEDGMENT

Republic of the Philippines)

City of Makati ) S.S.

BEFORE ME, a Notary Public, for and in the City of Makati, this 2ndday of October 2013

personally appeared:

Name Identification Card Issued On/At

____________________ ________________ _____________

____________________ ________________ _____________


____________________ ________________ _____________

____________________ ________________ _____________

all known to me to be the same persons who executed the foregoing instrument and hereby

acknowledged to me that the same is their free and voluntary act and deed.

This instrument consisting of two (2) pages, including this page on which this acknowledgment is

written refers to an EXTRAJUDICIAL SETTLEMENT OF ESTATE and has been signed by the parties and

their witnesses and sealed with my notarial seal.

WITNESS MY HAND AND NOTARIAL SEAL.

Doc. No. ____

Page No. ____

Book No. ____

Series of 2013.

AFFIDAVIT OF SELF-ADJUDICATION

AFFIDAVIT OF SELF-ADJUDICATION

I, MARIA B. DELA CRUZ, of legal age, Filipino, single and a resident of 6789 Washington Street,

Pio del Pilar, Makati City, after having been duly sworn to in accordance with law, depose and state:

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 26th day of September 2013 in Makati

City, Metro Manila, Philippines.


MARIA B. DELA CRUZ

Affiant

SUBCRIBED AND SWORN TO before me this 26th day of September 2013 in Makati City, Metro

Manila, Philippines, affiant exhibiting to me her Philippine Passport No. 123456 issued in Manila on

January 12, 2012 and valid until January 12, 2017.

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of 2013.

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