SIGNED IN THE PRESENCE OF:

____________________ _______________________

Witness
Witness

REPUBLIC OF THE PHILIPPINES)

CITY OF________________) S.S

Personally came and appeared before me this ___ day of _____201__ at_________________ with
Government Issued ID______________ known to me and to me known to be the same person who
executed the foregoing instrument, and acknowledged that the same is his/her free act and voluntary
deed.

This instrument consisting of __ pages, including this whereon the acknowledgment is written, has
been signed by the party and witnesses on each and every page threreof.

WITNESS MY HAND AND SEAL, at the place and on the date first above written.

NOTARY PUBLIC

Doc. No. ___;

Page No. ___;
Book No. ___;

Series of 201__