REPUBLIC OF THE PHILIPPINES )

PROVINCE OF _______________ ) SS
MUNICIPALITY OF ___________ )
BEFORE ME, this ________ day of _________, 20___ in the Municipality of
_______________, Province of ___________________, Philippines, personally appeared
_________________________, with Community Tax Certificates No. issued at
________________, on ____________, _______________ 20__, known to me to be the
same person who executed the foregoing instrument, and he acknowledged to me that
the same is his free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial
seal, the day, year and place above written.

Notary Public
Until ___________________
IBP No. ____________/ 01 Jan. 2010
PTR No. ____________/ 01 Jan. 2010
Roll No. 123456
MCLE No. III-123456
Doc No. ______;
Page No. ______;
Book No. ______;
Series of 200__.