201 Greenhills Mansion Bldg.

, Annapolis Street, San Juan

ACKNOWLEDGMENT RECEIPT

Date Received: _________________________________

Amount Received: _________________________________

From Payee: _________________________________

As payment for: ______________________________

If payment by check;

Bank, Check Number: ______________________________

Check Date: _________________________________

Received By: _________________________________

201 Greenhills Mansion Bldg., Annapolis Street, San Juan

ACKNOWLEDGMENT RECEIPT

Date Received: _________________________________

Amount Received: _________________________________

From Payee: _________________________________

As payment for: ______________________________

If payment by check;

Bank, Check Number: ______________________________

Check Date: _________________________________

Received By: _________________________________