ACKNOWLEDGEMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, _________________________, Filipino, of legal age, widow and a resident of

________________________________.
Witnesseth:
That I am indebted in the sum of ______________________ (Php_______________)
Philippine Currency, to __________________, also a Filipino, of legal age, widow and a
resident of _____________________;

That I shall pay the sum ___________________ (Php________________) unto the

said ______________________ within a reasonable period when said amount is already
available, but shall pay an interest of ______ Percent (____%) every month until such full
amount is fully paid by issuance of a check representing the agreed amount every month;

That in consideration of the same, the original copy of a title registered under the
name of ___________________________, with Transfer Certificate of Title No.
__________________ is given to ___________________ to serve as security but shall be
returned to me when the above-mentioned amount is fully paid;

IN WITNESS WHEREOF, I have affixed my signature this ___ day of ______, 2017
at _________, Philippines.

__________________________

SIGNED IN THE PRESENCE OF:

__________________ __________________

REPUBLIC OF THE PHILIPPINES)

____________________ ) Sc.
x-------------------------------------------x

ACKNOWLEDGMENT

BEFORE ME, this _____ day of ___________, _____ in the City of Santiago,
personally appeared the above-named persons with their respective competent evidence
of identity. All known to me to be the same persons who executed the foregoing
instrument consisting of one (1) page only including the page on which this
acknowledgement is written and signed by the parties and their instrumental witnesses, and
acknowledged that the same are their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial

seal on the date and place above written.

NOTARY PUBLIC

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