JURAT

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF _______________)
CITY/MUNICIPALITY OF ______ ) S.S.

[1] SUBSCRIBED AND SWORN to before me, in the municipality/ city of_____, this ____ day of
____, 2011, the affiant exhibiting to me his (any competent evidence of identity) issued by (issuing
agency) on (date of issue) at (place of issue).

[2] JUAN DELA CRUZ

NOTARY PUBLIC- Makati City
Appointment No. ____
Until December 31, 2010
Roll no. ____
PTR no. ____, date of issue, place of issue
IBP no. _____, date of issue, place of issue
Office Address:
Email:
Contact Number:
[3] Doc. No._____;
Page No. ____;
Book NO.____;
Series of 2011