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DEED OF ACKNOWLEDGMENT OF DEBT

KNOW ALL MEN BY THESE PRESENTS:

I, ________________________________, of legal age, Filipino,


(single / married / widow), and a
resident of _______________________________________________,
after being duly sworn to in accordance with law, witnesseth and
declare:

That I am indebted in the sum of _________________________


(P_____________), Philippine Currency, to Ms. CONNIE JANE
SHIMOSATO, who is also of legal age, (single / married / widow), and
a resident of _____________________________________________.

That I hereby promise and undertake to pay the said indebtedness


on or before ______________________________, in the
amount of _______________________________________________
(P_____________), with interest at the rate of _____________
(_____%) per centum per (month/annum) until fully paid.

IN WITNESS WHEREOF, I have hereunto set my hand this


___________________ in _____________, Philippines.

AFFIANT

SIGNED IN THE PRESENCE OF:

_________________ __________________
ACKNOWLEDGEMENT

Republic of the Philippines)


_________________________) S.S

BEFORE ME, personally appeared:

Name CTC Number Date/Place Issued

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

This instrument consisting of ____ page/s, including the page on which this
acknowledgement is written, has been signed on each and every page thereof by
the concerned parties and their witnesses, and sealed with my notarial seal.

WITNESS MY HAND AND SEAL, on the date and place first above written.

Notary Public

Doc. No.______;
Page No. ______;
Book No.______;
Series of 20___.

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