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City of _____________) SS


I, , Filipino, of legal age, married, and a resident of

_________Philippines, after being sworn to in accordance with law,
depose and state:

1. That by these presents, I hereby state that I was engaged as

___ on _______ by _________ from April 17, 2011 to January 15,

2. That I was disembarked due to End of Contract;

3. That I hereby acknowledge that I have received all salaries

and balance of wages onboard and upon return to Manila;

2. That in addition to the salaries and balance of wages

previously received, I hereby acknowledge to have received
from my employer the sum of Twenty-One Thousand, Nine
Hundred and 50/100 (Php 21,900.50) which is in full and
final satisfaction of my claims for provident fund and other
benefits that may be due me for the service which I have
rendered for the latter employer;

3. That I hereby declare that I have no further claims whatsoever

against my employer, its President, members of the Board,
officers or any of its staff and that I hereby release and
forever discharge all of them from any and all claims,
demands, cause of action of whatever nature arising out of
my employment with the latter;

4. I further agree that this WAIVER, RELEASE AND

QUITCLAIM may be pleaded in bar to any suit or proceeding
to which either I, or my heirs and assigns, may have against
my employer in connection with my employment with the
latter and that the payment which I have received as provided
herein should not in any way be construed as an admission of
liability on the part of my employer and is voluntarily
accepted by me and will, if need be, serve as full and final
settlement of any amount(s) due me or any claims or cause of
action, either past, present, future, which I may have in
connection with my employment with my employer;
5. As such, I finally make manifest that I have no further claim(s)
or cause of action against my employer nor against any
person(s) connected with the administration and operation of
the latter and forever release the latter from any and all

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.


SUBSCRIBED AND SWORN to before me, this _____________, by

the Affiant whom I have identified through competent evidence of
identity) and who exhibited his ____________ No. _____________ issued at
_____________ on _____________.


Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.