Republic of the Philippines }

Province of Nueva Vizcaya } S.S.

Municipality of Villaverde }

ACKNOWLEDGEMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, ____________________(Debtor) , Filipino, of legal age, single/married with

residence at___________________________, after being duly sworn to in accordance
with law, depose and declare:

1. That I am indebted in the sum of___________________ (PhP ____________)

Philippine Currency, to _________________________ (Creditor), who is also
of legal age, single/married, and a resident of
_______________________________________.

2. That I hereby promise and undertake to pay the said indebtedness unto said
____________________________ (Creditor), within a period of
____________________ (____) (months/years/days) from today, in the
amount of______________________________________ (PhP__________)
(monthly/daily) every ________________________________ with interest at
the rate of ___________________________________ (_____ %) per centum
per (month/annum) until fully paid.

IN WITNESS WHEREOF, the parties have hereunto affixed their signatures,

this_________ day of _____________,__________________, in _____________________,
Philippines.

__________________________________
Affiant

SIGNED IN THE PRESENCE OF:

_____________________________ _________________________________
Witness Witness