REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ____________ : S.S.

MUNICIPALITY OF ________ )

AFFIDAVIT OF RELEASE,
QUIT CLAIM AND WARRANTY
I, ________________________, of legal age, Filipino, married, with
residence and postal address ________________________, Philippines, after
having been duly sworn to in accordance with law, do hereby depose and say;

THAT —

1. Upon receipt from the ________________________ of the Centenarian Gift

of my deceased mother ________________________, I hereby waived,
quitclaim and release the DSWD from any liability whatsoever that may
arise by virtue thereof;

2. This Affidavit of Release, Quitclaim and Warranty is binding in my families

and our heirs.

IN WITNESS WHEREOF, I have hereunto affixed my signature this

________________________ at ________________________.

________________________
Affiant

SUBSCRIBED AND SWORN to before me this

________________________ at ________________________, affiant exhibited to
me his positive identification duly noted above below his signature, known to me
and to me known to be the same person who executed foregoing instrument and
acknowledged to me that the same is his free act and deed and that he voluntary
executed the same and understood all the contents thereof.

WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2021.