Republic of the Philippines )

City of ________________) S.S.

ACKNOWLEDGMENT RECEIPT

Received from (Name) ____________________________, with

residence at (Address)
_____________________________________ the amount
of (Amount it words) ___________________________________
(Amount in numbers) (P____________) as full payment/ as payment
for the (purpose of payment)
___________________________________________________________.

RECEIVED FULL PAYMENT:

_____________________________
NAME OF PAYEE

WITNESS:

1. __________________________        2. __________________________

            SUBSCRIBED AND SWORN to before me, this ___ day  of

__________year _______ at _____________________, Philippines Affiant
exhibiting to me his (Identification card), issued at ________________ on
(date issued) _____________________.

Doc. No. _______

Page No. _______
Book No. ______
Series of 20____