REPUBLIC OF THE PHILIPPINES)

CITY OF ____________ ) S.S.

x-------------------------------------x
AFFIDAVIT OF ADVERSE CLAIM

I, ______________________, of legal age, Filipino, married, and a resident of

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

1. That on ______________, I have entered into a Contract to Sell which was acknowledged on
the same date before Notary Public _____________________ of ________________ and
entered in her Notarial Register as Doc. No. _______________Series of 2013. A copy of the
said Contract is hereto attached as ANNEX A and made an integral part of this Affidavit;

2. That in the said Contract to Sell, I was the BUYER of a certain parcel of land designated as
_____________, containing an area of ________________________ SQUARE METERS,
covered by Transfer Certificate of Title No. _________________, more particularly described
as follows:

A parcel of land ____________________

3. That because I still have a balance on the purchase price in the

amount of P_________________ which is payable within THREE (3) DAYS from the
presentation by the SELLER to the BUYER of the title to the portion sold, which until now, no
title has yet been presented, it was stipulated in the aforementioned Contract that title
and ownership over the subject property will only be transferred upon full payment of the
same;

4. However, since the said Contract to Sell per se could not be annotated on the Title with
the Office of the Register of Deeds, I am therefore executing this Affidavit for the
purpose of attesting to the truthfulness of the foregoing allegations and in support of my
request for the annotation of an adverse claim over the parcel of land covered by the Transfer
Certificate of Title No. _______________.

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

___________________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE me this _____________ at

____________________, Philippines, Affiant having presented his Valid ID with No.
____________________ for identification purposes.

Doc. No. ........;

Page No. .......;
Book No. .......;
Series of 2016.