Page No.

JUDICIAL FORM 143, AS AMENDED

PORMULARYONG PANGHUKUMAN BLG. 143

NOTARIAL REGISTER OF of , Philippines, for the year

REHISTRO NOTARYAL NI ng Lungsod ng , Pilipinas, para sa taong

Under appointment made on the and expiring December 31,

Sa Nombramiento na ginawa noong ika- ng , na magtatapos sa Disyembre 31,

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

I HEREBY CERTIFY that during the past week instruments were executed before me
ginawa sa harapan ko
pinatutunayan ko na noong nakaraang lingo ang mga kasulatang sworn to
pinanumpaan

acknowledged
tinanggap

DATE:
NOTARY PUBLIC
Petsa Notaryo Publiko

* whether acknowledgment, oath, jurat, signature witnessing or copy certification