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RELEASE WAIVER AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

That We, THE IMMEDIATE FAMILY AND RELATIVES OF JOSHUS DIACOR


VELAROSO, Filipino, of legal ages, married and a resident of ____________________, do by
these presents acknowledge that for and in consideration of the amount of _____________
(P_____________) in cash, in hand received by us to our full and complete satisfaction, and the
payment and settlement received from PROVIDENCE INTEGRAL FREIGHT
SOLUTIONS, INC. and its officers and owners, of the hospital and medical bills and funeral
expenses incurred and will be incurred.

WE hereby absolutely release, completely clear, and forever discharge the said
PROVIDENCE INTEGRAL FREIGHT SOLUTIONS, INC. and his driver ROBERT
TAWAT from any action, cause of action, sum of money, liability, damages, claims and
demands whatsoever, which in law or in equity We have, or which We, our heirs, insurer,
successors and assigns hereafter may have upon or by reason of the injuries sustained by Us, and
the damage sustained by our motor vehicle with Plate No. 070104 arising from the accident
which happened on September 13, 2018 at Estaca, Compostela, Cebu and subsequently covered
by the Police Report hereunto attached, involving our said Fuso Fighter Wingvan 2016 registered
in the name of the undersigned with motor vehilce with Plate No. 1236-92431, with the intention
to completely and absolutely waive all our right of action, causes of action, claims and demands,
of whatever nature, arising from, or in connection with the aforementioned accident.

WE further warrant that we will institute no further action against the said Corporation,
its owners and/or the driver involved, arising from, by reason of, or in connection with, the
aforementioned vehicular accident.

WE declare that we have read this document and have fully understood its contents. WE
further declare that I voluntarily and willingly executed this Release, Waiver and Quitclaim with
full knowledge of my rights under the law.

IN WITNESS WHEREOF, WE have hereunto set my hand at _________ day of


_________________.

_________________________ _________________________
Name over Printed Signature Name over Printed Signature
AFFIANT AFFIANT

_________________________ _________________________
Name over Printed Signature Name over Printed Signature
AFFIANT AFFIANT

_________________________ _________________________
Name over Printed Signature Name over Printed Signature
AFFIANT AFFIANT
_________________________ _________________________
Name over Printed Signature Name over Printed Signature
AFFIANT AFFIANT

SIGNED IN THE PRESENCE OF:

_________________________ _________________________
Name over Printed Signature Name over Printed Signature
WITNESS WITNESS

SUBSCRIBED AND SWORN TO before me this _________ day of


_________________ affiant exhibiting to me their ____________________________.

Doc. No.
Page No.
Book No.
Series of 2018.