REPUBLIC OF THE PHILIPPINES )

_____________________ ) S.S

In the Municipality/City of _________, Province of ___________, on the _______day

of________________, personally appeared _______________, with his community Tax Certificate No.
_____________ issued on _________at ________________, known to me and to me known to be the
same persons who executed the foregoing instrument of ____________ over three (3) parcels of land,
which instrument consists of ____ pages including the page on which this acknowledgement is written,
signed by the parties at the left hand margin of each and every page by the party with my notarial seal
and said party witnesses , and sealed with my notarial seal and said party acknowledged to me that the
same is his free act and deed.

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

Doc. No.___
Page No.___
Book No.___
Series of (year)