REPUBLIC OF THE PHILIPPINES

)
CITY OF BACOLOD ) S.S.
X----------------------------------------------X

WAIVER, RELEASE AND QUITCLAIM

I,______________________, of legal age, Filipino, ______, and a resident
of________________, after having been duly sworn to in accordance with law, depose and
state:

1 I am a resident of __________________________________________________________.

2. That Central Negros Electric Cooperative, Inc. (CENECO) is undertaking a tree clearing
activity of two (2) Lonok Trees located along Ciocon Road, CENECO Main Building, Brgy. 26,
Bacolod City;

3. That on 03 August 2015, at around 2:30 PM, CENECO Safety Engineer explained to me the
hazards that might occur during the cutting of the Lonok Trees. Hence, they asked me to vacate
my place for me and my family’s safety during actual clearing or cutting.

4. That also, I was properly informed and advised by Brgy. Captain Antonio Arroz to
immediately vacate the place to avoid and/or prevent possible damage or injury during the
undertaking the said activity;

5. That as resident of the said place, I choose to stay and not leave my house constructed
thereon.

6. That I hereby WAIVE, RENOUNCE, FOREGO and RELEASE CENECO from whatever
claim/s that I may have against CENECO, its staff, officers and employees either civilly or
criminally in connection with this incident;

7. That in executing this affidavit, I was not tricked or forced by CENECO or by any of its
representatives or officers and that under oath, this Quitclaim may be pleaded to bar any claims
or proceedings which may have been taken in connection with this incident;

8. That I execute this Affidavit to attest and declare the truth of the foregoing facts and for
whatever legal purposes that this Affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of _____________ 2015
in Bacolod City, Negros Occidental, Philippines.

_________________________
Affiant

SUBCRIBED AND SWORN TO before me this _____ day of _____________ 2015 in Bacolod
City, Negros Occidental, Philippines, affiant exhibiting to me his ____________________, as
proof of competent identity.

Doc. No. _____ ;
Page No. _____;
Book No. _____;
Series of 2015.