Republic of the Philippines)

DAVAO CITY ) S.S.

WAIVER OF RIGHTS

I, HAZEL D. FLORES and ALVA ROSE D. FLORES both of legal age, Filipinos, and residents of 35
Quartz st., Cryrstal Meadows Subd. Sasa, Davao City after having been duly sworn to in accordance with
law, do hereby depose and say:
That I HAZAL D. FLORES and my sister ALVA ROSE D. FLORES who died on December 26,
2020 in Davao City with St. Peter Life Plan, Inc. under Policy Contract No. R10190927F, and more
particularly described as follows:

Plan Type : St. Dorothy

Plan Value : Php30,000.00

That we are hereby WAIVE, ASSIGN and TRANSFER our rights, claims, interests in, and
participation to, over the said Policy Contract with St. Peter Life Plan, Inc. in favor of
________________________, of legal age, Filipino, and a resident of
___________________________________________________

That we are executing this Waiver of Rights to attest to the truth of the above statements and this
will serve all legal purposes.

IN WITNESS WHEREOF, we have hereunto set our hands this ___________ day of
______________________ , at ______________________

HAZEL D. Flores and ALVA ROSE D. FLORES

Assignors

_______________________________
Assignee

Signed in the presence of:

_______________________ ________________________

ACKNOWLEDGEMENT
Republic of the Philippines)
Quezon City ) S.S.

BEFORE ME, A Notary Public for and in DDavao City on this ________ day of ___________, 2021,
personally appeared the above-named parties, both known to me and to me known who executed the foregoing
instrument and they acknowledged to me that the same are their free and voluntary act and deed.
WITNESS MY HAND AND SEAL.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 20___.