REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF NAVOTAS ) S.S.

ACKNOWLEDGEMENT

Acknowledging the receipt of the amount of Sixty Thousand Pesos (P60,000.00)

from _____________ which represents my share from the Cooperative;

Furthermore, receipt of the amount of Forty Six Thousand Pesos (P46,000.00)

from _______________ is hereby acknowledged which represents an amount of loan I
borrowed from the above mentioned cooperative.

IN WITNESS WHEREOF, I have hereunto set my hand this 28 th day of

December, 2014, in Novaliches, Philippines.

___________________________________
Jane Doe
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, this 28th day of August, 2014 in
San Pedro, Laguna, Philippines, affiants exhibiting to me the following:

NAME ID No.
Jane Doe

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2018.