(Acknowledgment of Debt)

DEED OF ACKNOWLEDGMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, _____________, of legal age, Filipino, (single / married / widow), and a resident of

_____________, after being duly sworn to in accordance with law, witnesseth and declare:

That I am indebted in the sum of _____________ (P_____________), Philippine

Currency, to _____________, who is also of legal age, (single / married / widow), and a resident
of _____________.

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

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ in

_____________, Philippines.

AFFIANT

SIGNED IN THE PRESENCE OF:

__________________ __________________

(ACKNOWLEDGMENT)