REPUBLIC OF THE PHILIPPINES)

) S.S.

ACKNOWLEDGMENT OF DEBT

I, ______________________ (Debtor), Filipino Citizen, of legal age, single /

married to __________________________ and a resident of
________________________________________, after having sworn to in accordance
with law, witnesseth and declare that:

That I am indebted in the sum of __________________________________

(Php _________________), 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 ______ (moths / years/ days)
from today, in the amount of _______________________________ (Php
_________________ ) monthly / daily every ________________________ with interest
at the rate of _____________ (___%) per month / annum) until fully paid.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

__________________ in ______________________.

Affiant

SIGNED IN THE PRESENCE OF:

______________________________ _______________________________

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
) S.S.

BEFORE ME, a Notary Public, for and in _____________________,

this _______________, personally appeared
____________________________ with __________________ issued on
_____________________ at ___________________, known to me and to
me known to be the same person who executed the foregoing instrument
consisting of _____ pages including this page wherein this acknowledgment
is written and he acknowledged to me that he fully understood the contents
thereof and that the same is the free and voluntary act and deed.

WITNESS MY HAND AND NOTARIAL SEAL.

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