PROMISSORY NOTE WITH REAL ESTATE MORTGAGE

I, __________________________________________________of legal age, Filipino and with residence at

__________________________________________________, promise to pay the remaining amount of
________________________________ Pesos to CHACON GENERAL HOSPITAL at its office located at
Brgy. Piot, Sorsogon City, for the hospitalization expenses and services rendered to (Name
of Patient/Patient’s No.) last _________________ under the following conditions;

1. The note is due and payable with _____ equal consecutive installments/payments
of _____________________________ (PHP _____________________________) in cash or check
deposited (Daily/Weekly/Semi-monthly/Monthly).

2. Upon failure or default of any payment of any installment due, all unpaid
installments shall become due and demandable. Unpaid installments/payments
shall bear interest rate of _____________________________ PERCENT (__________ %)
compounded (Daily/Weekly/Semi-monthly/Monthly).

3. To secure the payment of all obligations under this Note, I/We hereby transfer
and convey by way of first mortgage to the Mortgagee, its successors, and
assigns, the properties subject of this Mortgage, together with all the equipment,
accessories, substitutions or attachments which may now or from time to time
be used in connections with or attached to the said properties described,
hereinafter collectively referred to as “Mortgaged Properties” and now in the
possession of the MORTGAGOR.

Make: Motor No.:

Series: Serial/Chassis No.:
Type of Body: Plate No:
Year Model: File No.:

4. The BORROWER/MORTGAGOR is in default within the meaning and

contemplation of this Note, without need for a notice or any other act or deed, in
case the BORROWER/MORTGAGOR. The CREDITOR/MORTGAGEE shall have the
right, at its option, to declare the entire amount of all the obligation due and
payable, and likewise at its option, either cancel the sale or foreclose this
mortgage or file an ordinary civil action for the collection and/or such other
action or proceedings as may be allowed under the law.

5. The BORROWER/MORTGAGOR irrevocably appoints the

CREDITOR/MORTGAGEE, effective upon the nonpayment of this Note on
demand at maturity or upon the happening of any of the Events of Default, but
without any obligation on the CREDITOR/MORTGAGEE’s part should it choose
not to perform this mandate, as the attorney-in-fact of the
BORROWER/MORTGAGOR, to sell and dispose of any property of the
BORROWER/MORTGAGOR which may be in the CREDITOR/MORTGAGEE’s
possession by public or private sale, and to apply the proceeds thereof to the
payment of this Note. The BORROWER/MORTGAGOR, however, shall remain
liable for any deficiency

6. Any legal action arising out of this note shall be brought in the proper courts of
the City of Sorsogon or any place where the holder has any branch office, at the
option of the holder hereof.
 7. Acceptance by the holder thereof of payment of any installment or any part
thereof after due date shall not be considered as extending the time for the
payment of any of the installments aforesaid or as a modification of any terms
and conditions thereof and shall in no case release the makers of this note from
liability for the payment of the herein obligation.

8. Should the BORROWER/MORTGAGOR perform the obligation to pay

hereinabove cited indebtedness of
_____________________________________________________________ (PHP
_____________________________) together with accrued interest thereon, this real
estate mortgage shall at once become null and void of no effect whatsoever,
otherwise, it shall remain in full force and effect.

9. Any delay or failure in the performance by the BORROWER/MORTGAGOR shall

not be excused by the occurrence of a Force Majeure.

10.In case any provision in this Note shall be held to be invalid, illegal or
unenforceable, the validity, legality and enforceability of the remaining
provisions shall not in any way be affected or impaired thereby.

IN WITNESS WHEREOF, the parties have hereunto set their hands, this _____ day of
___________________________ 20 ___ at ___________________________ Philippines.

_____________________________________ _____________________________________
BORROWER/MORTGAGOR CREDITOR/MORTGAGEE

SIGNED IN THE PRESENCE

_____________________________________ _____________________________________

AFFIDAVIT OF GOOD FAITH

I/We severally swear that the foregoing Real EstateMortgage is made for the purpose of
securing the Obligations specified and defined in this instrument and for no other purpose;
that the Obligations are just and valid obligations; and that this Real Estate Mortgage is not
entered into for the purpose of fraud.

_____________________________________ _____________________________________
BORROWER/MORTGAGOR CREDITOR/MORTGAGEE

SIGNED IN THE PRESENCE

_____________________________________ _____________________________________

ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES )
_________________________ ) S.S.

            BEFORE ME A NOTARY PUBLIC for and in ____________, this ____________ personally
appeared to me the following:

Names Valid Id. No. Date/Place Issued

known to me to be the same persons who executed the foregoing instrument and who
acknowledged to me that the same is their voluntary act and deed.

            WITNESS MY HAND AND SEAL on the day and place first above written.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2020.