SUBSCRIBE AND SWORN TO BEFORE ME,

this __________________________, in Lucena City, affiant

exhibited to me (his/her) competent evidence of
identity _____________________ issued at______________,
Philippines on __________________.

BEFORE ME, a notary public in the City of

Lucena, Philippines, this ___________________ personally
appeared herein affiant his/her/their competent
evidence of identity, the details of which are written
above, known to me and to me known to be the same
person(s) who executed the foregoing instrument and
he/she/they further acknowledged to me the same is
his/her/their free act and voluntary deed.

WITNESS MY HAND AND SEAL on the date

and place first written above.