ACKNOWLEDGMENT RECEIPT

KNOW ALL MEN BY THESE PRESENTS:

This is to acknowledge that I,

_______________________________________________, of legal age, Filipino

citizen and a resident of

____________________________________________Philippines, received the

amount of _______________________________________

(PHP________________________________), from MATOD, of legal age,

Filipino, and A resident of Brgy. City, as full payment of the Fifty percent

of the hospital and medical expenses incurred by

____________________________________ as a result of the injuries he

sustained, in connection with the vehicular accident last Nov019 at

about 4:13am along Street particularly infront of Terminal. This is also

to acknowledge that the Compromise agreement executed by me and

MYLSSAD has been fully complied with

Done this _______________________________ at Laoag City.

_________________________________
 SUBSCRIBED AND SWORN to before me this _____________________

2019 at City, Philippines, affiant exhibited to me his competent evidence

of identity indicated below his name and signature.

Doc. No.
Page No.
Book
Series of 2019