WAIVER

THIS WAIVER AND RELEASE is made on ______________ by me, ______________, of the following
address: ____________________________.

I hereby waive, release and discharge _________________ of the following address,

________________________________, its officers, employees, representatives, agents, affiliates and
partners from the liability /damage arising from the accident which occurred on ___________, 2019
within the premises of ____________________.

I hereby acknowledge as follows:

1. I received from ____________ the total amount of PHP _______ representing the reimbursement
of the following: _____________________.

2. I have read this waiver and fully understand it.

3. I make this waiver voluntarily and without any form of cohesion.

IN WITNESS WHEREOF, I have executed this Waiver and Release this day and year written above.

_______________________________
[NAME]

In the presence of:

_______________________________ _______________________________

SUBSCRIBED TO AND SWORN before me this __________day of _________ 2019, affiant exhibiting to me
his/her ___________________ issued on_________ at ______________.

NOTARY PUBLIC
Doc. No. :__________
Page No. :__________
Book No :__________
Series of : 2019.