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REPUBLIC OF THE PHILIPPINES)

PASIG CITY ) S.S.

SUBSCRIBED and SWORN to before me this ____________, Affiant exhibited his


___________________, issued on _____________ and valid until ___________ at
______________.

Witness my hand and seal on this ____________ at the Pasig City.

Doc. No. _____;


Page No._____;
Book No. _____;
Series of 2019.

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