(Acknowledgment by an Individual - One-Party Instrument)

REPUBLIC OF THE PHILIPPINES) CITY/MUNICIPALITY OF ______) SS. x------------------------------------x ACKNOWLEDGMENT BEFORE ME, a Notary Public for and in the (Province/City/Municipality) of _____________, personally appeared _____________ with Community Tax Certificate No. _____________ issued on _____________ at _____________, personally known to me (or whom I have identified through competent evidence of identity) and who represented to me that his/her signature on the foregoing instrument was voluntarily affixed by him/her for the purposes stated in the instrument and who declared that he/she has executed the foregoing instrument as his/her free and voluntary act and deed. This Instrument consists of only ______ (____) page/s, including this page in which this acknowledgment is written, duly signed by _____________ and his/her instrumental witnesses on each and every page hereof. WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.

NOTARY PUBLIC

Doc. No. ______; Page No. ______; Book No.______; Series of 20____.