REPUBLIC OF THE PHILIPPINES )

CITY OF _______________ ) S.S.

BEFORE ME, this _____ day of __________, 2019, in the City of

_______________, personally appeared:

Name Competent Evidence of Identity Place and Date of Issue

_______________ ______________________________ _______________

_______________ ______________________________ _______________

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

This instrument, consisting of ___ pages, including the page on which this
acknowledgment is written, has been signed on the left margin of each and every
page thereof by _______________ and _______________ and their witnesses, and
sealed with my notarial seal.

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

NOTARY PUBLIC
Commission Serial No. _____
Until December 31, _____
Roll of Attorney _____
IBP No. _____/ Date/ Place of Issue
PTR No. _____/ Date/ Place of Issue

Doc. No. _____;

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