REPUBLIC OF THE PHILIPPINES)

City/Municipality of _____________) S.S.

x-----------------------x

WAIVER, RELEASE AND QUITCLAIM

I, _____________________, Filipino, of legal age, (single / married / widow), and a

resident of _____________, Philippines, after being sworn to in accordance with law, depose and
state:

1. That I am an employee of _____________________ assigned to work at

_____________________ premises in Taytay (“_____________________ premises”) as
___________________.

2. That I was involved in an accident which occurred on _______________________ at the

_____________________ premises.

3. That as a result of such accident, I have had to undergo four (4) operations on my foot /
leg at _____________________ Hospital;

4. Since the accident, my employer has covered all medical expenses including operation,
professional fees of doctors and medication in the total amount of
_________________________ (P____________);

5. That I have decided to voluntarily retire from my employment with

_____________________ effective on ___________________;

6. I hereby acknowledge to have received from my employer the following sums of money
for the following purposes:

Purpose Amount
Financial Assistance
Retirement
xxxx
TOTAL

7. I hereby acknowledge that the aforestated sum of ______________________

(P__________) BPI-Family Bank, Check No. __________ dated _______________,
received from my employer is in full and final satisfaction of my salary and other benefits
that may be due me for the service which I have rendered for the latter employer.

8. Further, I acknowledge that my employer has fully and finally satisfied all medical
expenses related to the injury I sustained from the accident that happened at the
_____________________ premises in Taytay.

1
 9. That I hereby declare that I have no further claims whatsoever against my employer, its
President, members of the Board, officers or any of its staff and that I hereby release and
forever discharge all of them from any and all claims, demands, cause of action of
whatever nature arising out of my employment with the latter;

10. I further agree that this WAIVER, RELEASE AND QUITCLAIM may be pleaded in
bar to any suit or proceeding (Civil, SSS, PhilHealth, Medicare, Labor, etc.) to which
either I, or my heirs and assigns, may have against my employer in connection with my
employment with the latter and that the payment which I have received as provided
herein should not in any way be construed as an admission of liability on the part of my
employer and is voluntarily accepted by me and will, if need be, serve as full and final
settlement of any amount(s) due me or any claims or cause of action, either past, present,
future, which I may have in connection with my employment with my employer;

11. As such, I finally make manifest that I have no further claim(s) or cause of action against
my employer nor against any person(s) connected with the administration and operation
of the latter and forever release the latter from any and all liability.

12. I hereby declare that I have read this document before signing it and the WAIVER,
RELEASE AND QUITCLAIM herby given is made willing and voluntarily and with
full knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

________________________
Affiant

SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is
personally known to me (or whom I have identified through competent evidence of identity) and
who exhibited his/her Community Tax Certificate No. _____________ issued at _____________
on _____________.

NOTARY PUBLIC

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2015.