REPUBLIC OF THE PHILIPPINES)

: S.S.
CITY OF MANILA )

AFFIDAVIT OF CLAIMANT

I, MR. ERWIN MANGLICMOT, of legal age and a resident of 0853 TEODORA

VILL. MAMPULOG VITAS CABANATUAN CITY, Philippines, after being duly sworn,
depose and say:

1. That I was employed by the Owners of “VSHIPS NORWAY/Pacific Ocean

Manning, Inc.” as FITTER for NINE months POEA approved term contract with
________ CBA. That I was discharged from the vessel “NORDIC JUPITER" and
repatriated to Manila on June 27, 2018 because the vessel has been sold.

2. That the amount of Severance / Termination Pay equivalent to pro-rate of my

basic wages upon disembarkation;

3. That in connection with my Severance / Termination Pay claim, I have

discussed this matter with Pacific Ocean Manning Inc. and after discussion, to my full and
complete satisfaction, I have freely and voluntarily agreed to a full and final settlement of all
my past, present and future claims against the vessel “NORDIC JUPITER" his Owners,
agents and operators with payment in an amount not exceeding $441.43.

4. That I understand that the final settlement of $441.43 represents all my past,
present and future claims due to me under the POEA employment contract and all
collective bargaining agreements and all labor laws and regulations, civil law or any other
law of whatsoever, in connection with the said claim;

5. That I consider the payment of $441.43 as an adequate compensation and I

have consulted the advice of my lawyer, family and relatives on the acceptance of this
payment.

6. That I have no further claims whatsoever in any theory of law against the
Owners of “VSHIPS NORWAY/Pacific Ocean Manning, Inc.”. That I certify and warrant
that I will not file any claim or complaint or prosecute any suit or action in the Philippines,
the United States of America, Panama, Japan or any other country against the shipowners
and/or the released parties herein after signing the Release of All Rights dated
___________2018.

7. That I understand that I will be made liable for damages in case of

breach/violation of this agreement.
 8. That I made this Affidavit Statement voluntarily and with my own free will.

9. That I declare under penalty of perjury under the law that the foregoing is true
and correct.

City of Manila, __________, 2018.

.

FTR ERWIN MANGLICMOT

(Position)

SUBSCRIBED AND SWORN to before me this ____ day of _________2018.

Affiant exhibited to me this Community Tax Certificate No. _________ issued at _________
on _____________.

_____________________
Page No.: ______________; NOTARY PUBLIC
Book No.: _____________; Until _____________
Series of ______________. PTR No. __________
Issued at __________
Issued on __________