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ACKNOWLEDGEMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, ______________________________, Filipino, of legal age, single / married to


___________________________with postal address at
___________________________________________________________ witnesseth:

That I am indebted in the sum of________ (amount in words) __________ PESOS (P:
000,000.000), Philippine Currency, to _________________________________________ also a
Filipino, of legal age, single / married to _______________________________________ with
postal address at ______________________________________________________.

That I shall pay the sum of _________________________________ PESOS (P 000,000.00) unto


the said ____________________________ within a period of (state the repayment period -
days/months/years) from the execution hereof , with interest at the rate of (state the
interest rate in words) ( 0.0 %) percent per year.

IN WITNESS WHEREOF I have affixed my signature hereto this _____ day of ____________,
200_ at ___________________________. at___________________________, Philippines.

_____________________________
(Printed Name Over Signature)

WITNESSES:

________________________ _______________________

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES)


_____________________________ ) SS.

BEFORE ME, a Notary Public, this ____________day of ________________, personally


appeared the following:

Name CTC Number Date/Place Issued

(Name of Debtor) 10000000 January 15, 2008 / Manila

IN WITNESS WHEREOF, I have hereunto set my hand the day, year and place above
written.

Notary Public

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


Page No. .......;
Book No. .......;
Series of 200_.