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S WHEREOF, I have hereunto set my hand this day of 20 , at , Philippines. Signature over Printed Name SUBSCRIBED AND SWORN to before me, a Notary Public for and in this day of 20 , affiant exhibiting to me his/her CTC No. , issued on at . Doc. No. Page No. Book No. Series of 20 Notary Public SINUMPAANG SALAYSAY Ako si , sapat ang gulang, Pilipino, at naninirahan sa.

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