Republic of the Philippines )

Province of _____ )
Municipality of _________ ) S.S.

WAIVER OF RIGHT TO CLAIM

We, __________, _____________, ____________, ________________,_________, all of legal

ages, Filipinos and residents of ____________________, after having been duly sworn to in
accordance with law, hereby depose and state that:

1. We are the surviving legitimate heirs / beneficiaries of the late ______________;

2. For reasons of gratuity and generosity, we hereby waive all our rights and interests to claim the
Survivorship Benefits of the aforementioned deceased in favor of our father ____________.;
and

3. We are executing this waiver freely and voluntarily to attest to the foregoing facts and for
whatever legal purpose it may serve.

IN WITNESS WHEREOF, we have hereunto affixed our respective signatures this

_____________ in __________________.

Name of Affiant Signature Valid ID

1 ____________________ ____________________________

2 ____________________ ____________________________

3 ____________________ ____________________________

4 ____________________ ____________________________

5 ____________________ ____________________________

6 ____________________ ____________________________

7 ____________________ ____________________________

SUBSCRIBED AND SWORN TO before me this ____________ in ___________, affiants

exhibiting to me their competent evidence of identity indicated above.

Doc. No. ____;

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