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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.

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