Republic of the Philippines )

_______________________ ) Sc

ACKNOWLEDGMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, JUAN DELA CRUZ (Debtor), Filipino, of legal age,

single/married to __________________________ with residence at
____________________________, after being duly sworn to in accordance with law,
witnesseth and declare:

That I am indebted in the sum of _____________________________

(P___________________), Philippine Currency, to _____________________ (Creditor),
who is also of legal age, (single / married / widow), and a resident of
___________________________________________;

That I hereby promise and undertake to pay the said indebtedness unto said
______________________________ (Creditor) within a period of
_____________________________ (____) (months/years/days) from today, in the Amount of
___________________________________ (P___________________) (monthly/daily)
every______________________________ with interest at the rate of
_____________________________ (______%) per centum per (month/annum) until fully paid.

IN WITNESS WHREOF, the parties have hereunto affixed their signatures, this ______
day of ____________________, 20____, in Quezon City, Philippines.

_____________________________
Affiant

SIGNED IN THE PRESENCE OF:

______________________ ______________________

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
QUEZON CITY ) Sc.

Personally came and appeared before me this __________________, at Quezon

City, the aforesaid parties exhibited to me their identification cards, known to me and to
me known to be the same persons who executed the foregoing instrument, and
acknowledged that the same is their free act and voluntary deed.

WITNESS MY HAND AND SEAL, at the place and on the date first above written.

Doc. No._____;
Page No._____;
Book No._____;
Series of 2018.