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ACKNOWLEDGEMENT RECEIPT

I, _______________________________________, of legal age, Filipino, widow,


and a resident of ____________________________________________________, do
hereby acknowledge from _______________________________________, as
represented by _______________________________________, of legal age, Filipino,
married, and a resident of ____________________________________________________,
the full payment of the following amounts:

1. ____________________________________________________, PHILIPPINE
CURRENCY on ____________________________________________________;
2. ____________________________________________________, PHILIPPINE
CURRENCY on ____________________________________________________; and
3. ____________________________________________________, PHILIPPINE
CURRENCY on ____________________________________________________.

The above-mentioned amounts are considered as payment for the


____________________________________________________ of
____________________________________________________.

RECEIVED BY:

____________________________________________________

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