Republic of the Philippines)

City of ) S.S.
x----------------------x

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

_________________ __________ at.

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Affiant

SUBSCRIBED AND SWORN to before me ____ day of _____________

_______, in , affiant exhibiting to me his competent evidence of identity by way of _with
the license number __ issued at _on _.

Doc. No.: _____

Page No.: _____
Book No.: _____
Series of 2021
Notary Public