REPUBLIC OF THE PHILIPPINES

MAKATI, METROPOLITAN MANILA

QUIT CLAIM
I, ____________________________________, of legal age, single/married with residence and postal address at
_____________________________________, after having been duly sworn in accordance with the law, do
hereby depose and say: That, for and, in consideration of the amount of PESOS:
______________________________________________________________________(P__________), Philippine
currency, which I hereby acknowledge to have received to my full and complete satisfaction, representing full
payment of my unpaid salaries, share of the 13 th Month Pay and such other benefits, due to me, I am hereby
releasing ANTHEM SOLUTIONS, INC. and render free ANTHEM SOLUTIONS INC and harmless from any further
claims that may arise from my having been employed by.

That I fully understand that the said amount has been correctly computed with my express conformity and I hereby
waive all my rights to make any or additional claims, monetary or otherwise, from the said employer.

That, I hereby release, remise and forever quitclaim unto the ANTHEM SOLUTIONS INC. and its employees all of
my rights, causes of action, claims and interest due her as my former employer, by reason of my
resignation/termination from it, thereby releasing and discharging said ANTHEM SOLUTIONS INC and its
employees from all liabilities, money claims or otherwise.

IN WITNESS WHEREOF, I have hereunto affixed my signatures on this __________ day of ______________,
2019, at ______________, Philippines.

___________________
Affiant

SUBSCRIBED AND SWORN to before mo on this ________________________ day of _________ 2019____ by

____________________________ affiant having exhibited to me his/her Residence Certificate NO:
___________________________, issued at ___________, on ____________.

DOC NO. _________

PAGE NO. _________

BOOK NO. _________

SERIES NO. _________

HRF - 013