ACKNOWLEDGEMENT OF DEBT with PROMISSORY

NOTE
KNOW ALL MEN BY THESE PRESENTS:
I,
_____________________________________,
married to
_________________________________________ with

Filipino,
postal

of legal age, single /

address

at

______________________________________________________
witnesseth
That
I
am
indebted
in
the
sum
of
___________________________________________________
(amount
in
words)
___________________ PESOS (
), Philippine Currency to MR. JOSE
VAN P. TAN also a Filipino, of legal age, single with postal address at Brgy. No. 1,
Poblacion, Calbiga, Samar.
That I shall pay the sum of _________________________________ PESOS (P
000,000.00) unto the said JOSE VAN P. TAN or his duly authorized representative
within a period of ___________________________ (state the repayment period
days/months/years) from the execution hereof, with the interest at the rate of (state
the interest rate in words) ( __________.0 %) percent per month.
IN WITNESS WHEREOF I have affixed my signature hereto this _____ day of
________________ 20___
at
_______________________, at
_________________________ Philippines.

________________________________
(Printed Name Over
Signature)
WITNESSES:
________________________________

________________________________

ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES
PROVINCE OF SAMAR
MUNICIPALITY OF CALBIGA

SS.

BEFORE ME, a Notary Public, this _______________ day of ___________________,

personally appeared the following:
Name

CTC Number

Date/Place Issued

and their witnesses who is known to be the same person who executed the forgoing
instrument denominated as Acknowledgement of Debt with Promissory Note and
acknowledged before me that the same are their free act and deed.
Witness my hand and seal on date and place above written.

NOTARY
PUBLIC
Doc. No. ___________
Page No. ___________
Book No. _________
Series of 20_____