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____________________________ ) s.s.


I, ________________________, Filipino, of legal age, single/married to

____________________/widow/widower, and a resident of __________________, after having
been duly sworn in accordance with law, hereby depose and say:

1. That I am an employee of ______________________, having connected therewith as

_____________________, since _______________;

2. That I have a letter of resignation with the company effective


3. That I hereby acknowledge to have received from my employer the sum of

_______________________________ (Php ___________) which is in full and final
satisfaction of my salary 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, CEO, Chairman and 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 (Civil, Labour, SSS, PhilHealth, Medicare, etc.) 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 liability.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___day of

__________, 20_____ at ____________, Philippines.

(Signature of Affiant over Printed Name)

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for

_________(City/Province)____________ this ____th day of ____________ 20___. Affiant
personally came and appeared with _____________(Competent Evidence of Identity)______
issued by the _________(Government Agency)______ on ___(date)__ at
________(place)_________, bearing his photograph and signature, known to me as the same
person who personally signed the foregoing instrument before me and avowed under penalty of
law to the whole truth of the contents of said instrument.
ATTY _________________________________
COMMISSION NO. _____________________
NOTARY PUBLIC for _____________________
OFFICE: __________________________________
ROLL NO. 00001
IBP Lifetime Roll No. 1234567 ; 01/07/07 ; LA UNION
PTR NO 1234567 ; 01/07/07 ; LA UNION
MCLE COMPLIANCE No. __________; July 7, 2007

Doc. No. ___

Page No. ___
Book No. ___
Series of 2018.