Republic of the Philippines)

City of Bacolod )S.S.

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

WAIVER, RELEASE AND QUITCLAIM

I, ______________, Filipino, of legal age, married, and a resident of

___________________, Philippines, after being sworn to in accordance with law,
depose and state:

1. That I hereby acknowledge to have received from __________________, the sum of

__________________________________;

2. That I hereby declare that I have no further claims whatsoever against

_____________________, and that I hereby release and forever discharge
_________________________________________ from any and all claims, demands,
cause of action of whatever nature arising out of the death of my husband;
 

3. 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 ______________________ in
connection with the death of my husband 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 ___________________________ and is voluntarily accepted by me and will,
if need be, serve as full and final settlement of any amount(s) due or any claims or
cause of action, either past, present, future, which I, or my heirs and assigns, may
have in connection with my husband’s death;

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

IN WITNESS WHEREOF, I have hereunto set my hand this _______________

at Bacolod City, Negros Occidental, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN TO before me this ________________. The

affiant, whom I identified through her Identification Card with number
__________________________, personally signed the foregoing instrument before me
and avowed under penalty of law to the whole truth of the contents of said instrument.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.