REPUBLIC OF THE PHILIPPINES )

_____________________________________ ) S.S.

ACKNOWLEDGMENT

BEFORE ME, a Notary Public in and for ________________________________, this _____ day of
_______________________ personally appeared:

Name Competent Evidence of Identity

known to me and by me known to be the same persons who executed the foregoing
document and they acknowledged to me that the same is their free and voluntary act and
deed.

This instrument consisting of two (2) pages including where this acknowledgment is
written, has been signed by her and refers to a ______________________.

IN WITNESS WHEREOF, I have hereunto set my hand the date and at place above
written.

Doc. No.: _____;

Page No.: _____;
Book No. _____;
Series of 20___.