Republic of the Philippines) S.

S
City of Tabuk) S.S.

WAIVER OF RIGHTS TO CLAIM

I, VIRGILIO G. DURAN, of legal age, Filipino, and resident of Brgy.

Santan, Sta. Rita, Samar, after having been duly sworn to in accordance with
law, hereby depose and say:

1. That I am the legal spouse of the late THELMA B. DURAN who passed away
last September 22, 2014 at the Divine Word Hospital, Tacloban City;

2. That upon her death, it was my daughter SHIRLEE B. DURAN-ZETA who

shouldered the funeral expenses, since she has a fully paid Memorial Plan with
the St. Peter Life Plan, Inc., and had it reassigned to her mother;

3. That the above-named deceased was a member/retiree of the Government

Service Insurance System during her lifetime; and as such, one of its benefits
is the funeral/burial claim;

4. That being the one who paid for the reassigned memorial plan, my daughter
SHIRLEE B. DURAN-ZETA, is entitled for the said claim;

5. That for reasons of gratuity and generosity, I hereby waive all my rights and
interest to claim the Funeral/Burial Benefits of the afore-mentioned deceased
with the GSIS in favor of my daughter, SHIRLEE B. DURAN-ZETA;

6. That I execute this waiver, freely and voluntarily to attest to the foregoing
facts and statements and for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 4th

day of July 2021, Tabuk City, Kalinga, Philippines.

VIRGILIO G. DURAN
Affiant

SUBSCRIBED AND SWORN to before me this 4th day of July 2021,

Tabuk City, Kalinga, Philippines.

Doc No.
Page No.
Book No.
Series of 2021