KASIPAG MICROFINANCING, INC.

Head Office
Papaya, San Antonio, Nueva Ecija

CO-MAKER'S STATEMENT

Name of Co-Maker:____________________________________________ Age:__________

TO: Kasipag Microfinancing, Inc.

I agree to become a co-maker with the applicant Mr./Mrs./Ms. ____________________________________

signing the promissory note which will evidence the loan applied for if granted for an amount not exceeding
____________________________________________P(______________) l am aware of the responsibilities
which l will assume such a note. I authorize you to obtain such information as you require concerning the
statements made here under and agree that this document shall remain your property whether or not the
loan is granted.

(Fill all blanks, writing "No" or "None" when necessary to complete information)

PERSONAL INFORMATION
Home Address:___________________________________________________________________________
No. of years in this address: ______________________ No. of years in this community: _____________
Married to: ___________________________________ No. of Dependents: _______________________
Salary, Commission, or other regular income per month: P______________________________________
Other income: Slate Source: _____________________ P ______________________________________
Your Bank: ___________________________________ Checking Account ( ) Savings Account ( )
Name of your Company: ________________________ Address: ________________________________
Your Position: ________________________________ How long: _______________________________
Name of Superior: _____________________________

___________________________ ___________________________________
Date signed: (Signature of Co-Maker)