Republic of the Philippines )

Province of ______ ) s.s.

Municipality of_______ )

ACKNOWLEDGMENT RECEIPT

I, ________________________, of legal age, single, Filipino citizen and presently residing at Bliss,
Brgy. Poblacion, Inopacan, Leyte, (VENDOR), hereby acknowledge receipt of the amount of
SEVENTY-FIVE THOUSAND PESOS (Php 75,000.00) Philippine Currency from
__________________________, of legal age, married, Filipino citizen and presently residing at Brgy. Can-
angay, Inopacan, Leyte, (VENDEE) as payment in purchasing a portion of _______ square meters (___
sqm) piece of land from a lot with an area of 038437382 square meters designated as CAD Lot No.
____, covered by Tax Declaration of Real Property No. _______ in the name of __________ located at
_______ and more particulary described as follows: bounded on the North by Lot No. 960, 959; South
by Lot No. 956; East by Lot No. 972, 973 and West by Lot No. 955, containing an area of 0.5026
hectare, more or less and with an assessed value of Php 11,057.20.”

IN WITNESS WHEREOF, the parties hereunto affixed their signature this ___ day of April,
2020 __________, Philippines.

____________________________ __________________________
VENDOR/AFFIANT VENDEE/AFFIANT
ID No.:______________________ ID No: ________________________
Issued By:_______________________ Issued By: __________________________

Signed in the Presence of:

_____________ ________________

SUBSCRIBED and SWORN TO before me this ___ day of April, 2020 at ______________,
Philippines, affiants exhibiting to me their valid proof of identification as indicated above.

Doc. No.: ;
Page No.: ;
Book No.: ;
Series of 2020.