NOTARIAL REGISTER OF

ATTY. JAYDEE PEREGRINO-CO

Under appointment made on the ____________ of

_____________________________________,

ENTRY
NUMBER

TITLE/DESCRIPTION
OF INSTRUMENT

Page ____

Judicial Form No. 143, as amended

NAMES & ADDRESSES OF

PARTIES

NAMES & ADDRESSES

OF WITNESSES

of _____________________________________, Philippines, for the year

and expiring December 31
COMPETENT
EVIDENCE
OF IDENTITY

DATE & TIME OF

NOTARIZATION

TYPE OF NOTARIAL
ACT

I HEREBY CERTIFY that during the past week

me.

FEES &
O.R. NO.

OTHER PLACE OF
NOTARIZATION OTHER
THAN OFFICE OF
NOTARY PUBLIC
AND/OR REMARKS

executed
instruments were

sworn to

Acknowledged

Date _____________________________________

PEREGRINO-CO

ATTY. JAYDEE
Notary Public

before