ACKNOWLEDGEMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS

I, ___________________________, Filipino, of legal age, single/married to

____________________ with postal address at _____________________________ witnesseth:

That I am indebted in the sum of ________________________ ( Php. ______) , Philippine

Currency, to MRS. HELEN B. ASUPAN also a Filipino, of legal age with postal address at 1464-A
Espina Street, Surigao City.

That I shall pay the sum of _________________ (Php. ___ ) to MR. JONATHAN C.
MACABODBOD within a period of ______________________ from the execution hereof, with
an interest of Five Pesos (Php. 5.00) per One thousand Pesos (Php. 1,000.00) per day. Further I
understand that I shall pay ______________ every month on or before on ____ day of the
month from the execution and failure to pay the said amount will acquire an additional penalty
at the rate of ten percent (10%) per month.

IN WITNESS WHEREOF, I have affixed my signature hereto this ___ day of ____, 2014 at
_____________________.

______________________________
(Signature over Printed Name)

WITNESSES:

_____________________________ __________________________

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES)

________________) SS.

BEFORE ME, a Notary Public, this _______________________, personally appeared the

following:

Name CTC Number Date/Place Issued

IN WITNESS WHEREOF, I have hereunto set my hand the day, year and place above written.

NOTARY PUBLIC

Doc. No. __________ ;

Page No. __________ ;
Book No. __________ ;
Series of 20___.