REPUBLIC OF THE PHILIPPINES )

PROVINCE OF OCC. MINDORO )S.S

CITY/MUNICIPALITY OF SABLAYAN)

WAIVER AND QUITCLAIM

I/WE,(name/s of children of deceased depositor),all of legal age, widower, Filipino, and
with residence and postal address at_______________________, Sablayan, Occidental Mindoro;

1. We are the surviving spouse/children and sole heirs of the late MR. ERNESTO D.
GREGORIO of (state his address) who died on _________________.Copy of his
death certificate is attached s Annex “A.” Meanwhile, copies of our birth
certificate/marriage contract are attached as Annex “B.”

2. During her lifetime, Ms. Javier maintained a savings account with UCPB Savings
Bank La Castellana Branch under SA#930-105186-8 which, at the time of her death,
had a balance of Philippine Peso: Five Thousand Twelve and 43/100
(P5,012.43).Copy of the passbook/ATM is attached as Annex “C”.

3. Upon our execution of this Affidavit, surrender of the passbook/ATM, submission of

the documents mentioned in the Affidavit, and receipt of the proceeds of SA#930-
105186-8 in the sum of Philippine Peso: Five Thousand Twelve nd 43/100
(P5,012.43), I/WE hereby waive, quitclaim, release, and discharge UCPB Savings, its
directors, officers, employees, agents from any and all liability and actions
whatsoever, by reason of or arising from the release of the said sum in my/our favor

4. I/WE declare that we have read this document and have fully understood its contents,
and that we have voluntarily and willingly executed this Release, Waiver and
Quitclaim with full knowledge of our rights under the law.

IN WITNESS WHEREOF, we have hereunto set my/our hand at _____________,this

___day of __________, 2019.

_____________________ _____________________
Affiant Affiant

SUBSCRIBED AND SWORN to before me this ___day of ____, 2016, affiants

exhibiting to me their SS/TIN/Driver’s License with Nos. __________ and _________,
respectively.

Doc No. ______

Page No.______
Book No. _____
Series of 2019