Acknowledgment of Debt)

DEED OF ACKNOWLEDGMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, _____________, of legal age, Filipino, (single / married / widow), and a resident of

_____________, after being duly sworn to in accordance with law, witnesseth and declare:

That I am indebted in the sum of _____________ (P_____________), Philippine Currency, to

_____________, who is also of legal age, (single / married / widow), and a resident of
_____________.

That I hereby promise and undertake to pay the said indebtedness unto the said _____________
within a period of _____________ (_____) (months/years/days) from today, in the amount of
_____________ (P_____________) (monthly/daily) every _____________ with interest at the
rate of _____________ (_____%) per centum per (month/annum) until fully paid.

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

Philippines.

AFFIANT

SIGNED IN THE PRESENCE OF:

_________________ __________________

(ACKNOWLEDGMENT)