NON-NEGOTIABLE PROMISSORY NOTE

WITH DEED OF ASSIGNMENT

KNOW ALL MEN BY THESE PRESENTS:

_________________
(Date)

For the value received for the payment for Phil-Am Life Accident Shield Prime Plan 900, I
__________________________________________ (the “Principal Borrower”), an employee of the Elizabeth
Bakery and Grocery (the “Company”), promise to pay to the company the sum of Philippine PESOS: One
Thousand (PhP 1,000.00) in monthly installments of P 100.00 each payday (weekly) starting on ____________
and thereafter on every corresponding date of the succeeding agreed installment periods.

For the payment of all installments or amounts due and demandable under this Promissory Note, I hereby
assign and transfer an amount equivalent to the said weekly installment the salaries, wages, allowances and other
benefits payable to me from the Company.

In addition, in the case of termination or resignation and that the said loan will be left unpaid due to such
cessation of salary, I do hereby grant the Company, its management, and assign the full power and authority to
deduct the remaining amount from my remaining pays. If the said remaining pay is found to be lacking, I declare
that I am still in debt to the company and promise to pay in any means possible the remaining amount for a
maximum of one month beginning the effectivity of my separation from the company until such debt is settled.

Conforme:

Signature of Borrower over printed name

Signed in the presence of:

_____________________________ _____________________________
Witness Witness
Signature Over Printed Name Signature Over Printed Name

ACKNOWLEDGEMENT
Republic of the Philippines)
______________________)S.S.
x_____________________x

BEFORE ME, a Notary Public, for the City/Province of _____________________, Philippines, on this
day of __________, ________, personally appeared the following persons with their Community Tax Certificate
as hereunder indicated:

Name CTC No. Date/Place Issued

1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________

known to me and to me known to be the same persons who executed the foregoing instrument and they
acknowledged to me the same in their voluntary act and deed and that of the entry represented.

WITNESS MY HAND AND SEAL on this _________ day of __________________, ___________ at

_______________________________.

Notary Public

Doc. No. _______________

Page No. _______________
Book No._______________
Series of _______________