AFFIDAVIT OF QUITCLAIM, COMPROMISE AND WAIVER

I, _________ of legal age, a Filipino and resident of ________________, under oath depose and say
THAT:

1. I applied for overseas employment with and was deployed by _____________ with office and
business address at, __________________

2. For in consideration of the amount of _______________ (PHP ______00) in cash representing

my claim and which I hereby and duly acknowledge as full compensation/settlement of my
unpaid salaries, medical assistance, transportation allowance, salary differentials, salary
deductions, including refund of ticket from abroad and claim for domestic fares, retrieval of
passport and documents, medical/disability benefits, financial assistance, year-end incentive,
insurance benefits under mandatory insurance (RA 10022), unexpired portion of the contract,
damages and other benefits under the Philippine and host country law to which I am entitled
under whatever reason/s.

3. That the above payment shall constitute the complete, absolute and final settlement and final
release of my Recruitment Agency and their employees, officers, stockholders and foreign
employer and principal.

ANG LAHAT NG NILALAMAN NG SALAYSAY NA ITO AY IPINALIWANAG SA AKIN SA

WIKANG TAGALOG NA AKING NAIINTINDIHAN AT SINASANG- AYUNAN NG KUSANG
LOOB NA WALANG PAG AALINLANGAN, PAMIMILIT O PANANAKOT.

IN WITNESS WHEREOF, I have hereunto set my hands this ___day of ___ 20___ in
____City, Philippines.

___________
Affiant

SUBSCRIBED AND SWORN to before me this _____ day of ____ 20___ in ___________
City, Philippines affiant exhibited to me her ___________ I.D. with I.D. number _______________,
Philippines.

Doc. No.
Page No.
Book. No.
Series of 2019