Judicial Form No.

143, as amended
Pormulariong Panghukuman Blg. 143 Page No. ____ Book No. ____
NOTARIAL REGISTERED of MR. _______________________ 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,

ENTRY TITLE/DESCRIPTION NAME & ADDRESSES NAME & ADDRESSES COMPETENT EVIDENCE DATE & TIME OF TYPE OF FEES & OTHER PLACE OF
NUMBER OF INSTRUMENT O PARTIES OF WITNESSES OF IDENTITY NOTARIZATION NOTARIAL O.R. NO. NOTARIZATION OTHER
ACT THAN OFFICE OF NOTARY
PUBLIC AND/OR
REMARKS

executed
isinagawa

HEREBY CERTIFY that during the past week ______ instrument were sworn to before me
Pinatunayan na noong nakaraang linggo ______ ang mga kasulatan pinanumpaan sa harapam ko
______ acknowledge
tinanggap
DATE ___________________________________________ ____________________
Petsa Notary Public

Whether acknowledgement, oath, jurat, signature witnessing or copy certification Notaryo Publiko