Judicial Form No.

143, as amended

NOTARIAL REGISTERED of MR. _______________________

Page No. ____ Book No. ____

of _______________________, Philippines, for the year

Rehistro Notaryal ni G.

ng ________________________________Pilipinas, para sa taon

Under appointment made on the _______________________

and expiring December 31, 201__

Sa nombramiento na ginawa noong ________________

na magtatapos sa Disyembre 31,

Pormulariong Panghukuman Blg. 143

ENTRY
NUMBER

TITLE/DESCRIPTION
OF INSTRUMENT

NAME & ADDRESSES

O PARTIES

NAME & ADDRESSES

OF WITNESSES

COMPETENT EVIDENCE
OF IDENTITY

DATE & TIME OF

NOTARIZATION

TYPE OF
NOTARIAL
ACT

FEES &
O.R. NO.

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

executed
isinagawa
HEREBY CERTIFY that during the past week ______
Pinatunayan na noong nakaraang linggo

______
______

instrument were
ang mga kasulatan

sworn to

before me

pinanumpaan

sa harapam ko

acknowledge

tinanggap
DATE ___________________________________________
Petsa
Whether acknowledgement, oath, jurat, signature witnessing or copy certification

____________________
Notary Public
Notaryo Publiko