DEED OF ACKNOWLEDGMENT OF DEBT

WITH AUTHORITY TO DEDUCT WAGES/SALARIES

I, _________________, Filipino, married, of legal age, and a resident of

__________________, Cebu City, Philippins, after being duly sworn to in accordance with
law, witnesseth and declare:

1. That I received from a customer the sum of ₱10,610.00 however, I remitted to the
office of ______________ the sum of ₱5,500.00;

2. That I declare that I used the sum of ₱5,110.00 for my mother’s medication without
having informed my employers of such fact;

3. That I acknowledge that I am indebted to my employer _____________ in the sum

of ₱5,110.00 for which I promise and undertake to pay said indebtedness through
salary deduction until fully paid;

4. That I expressly agree that my salary be deducted for the shortage stated above;

5. That I understand that I shall be responsible for all legal consequences should the
same happen again in the future.

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

the City of Cebu, Philippines.

____________________
Affiant

REPUBLIC OF THE PHILIPPINES )

City of Cebu ) S.S.

BEFORE ME, a Notary Public for the City of Cebu, Philippines, personally
appeared ___________________ whom I have identified through competent evidence of
identity and who represented to me that his signature on the foregoing instrument was
voluntarily affixed by him/her for the purposes stated in the instrument and who declared
that he has executed the foregoing instrument as his/her free and voluntary act and deed.

WITNESS MY HAND AND SEAL this _____________ at Cebu City, Philippines.

Doc. No.

Page No.

Book No.

Series of 2020.