ACKNOWLEDGMENT

(Simple Form)

REPUBLIC OF THE PHILIPPINES )

CITY OF ____________________ ) S.S.

BEFORE ME, this ____ day of ____, 2___ in the City of _______, personally appeared:

Name Competent Evidence of Place and Date of Issue

Identity
________________________ ________________________ ________________________
__________________ __________________ ________________________

known to me to be the same person who executed the foregoing instrument, and acknowledged that the
same are their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal on the date
and place above written.

Doc. No. __________; NOTARY PUBLIC for __________

Page No. __________; Commission Serial No. _________
Book No. __________; Until December 31, ____________
Series of __________. Roll of Attorney _______________
IBP No. ____/Date/Place of Issue
PTR No. ____/Date/Place of Issue