Republic of the Philippines)

_________________________) S.S.

QUITCLAIM

I, _________________________________,of legal age, Filipino and resident of

_______________________________________, after having been sworn to in accordance with law, state
that:

1. I am working at ______________________________ and my immediate supervisor

is _________________________________;

2. That while on work, I had accident which is the fault of one of my co-workers,
namely ____________________________;

3. My boss ______________________, helped me in the hospitalization and

medication;

4. Because of this, I will not held accountable anyone especially

_________________________________________, its affiliates, officers and
employees for the death of our daughter;

5. I understand that the assistance extended to me by

___________________________________________ at this difficult time is not an
acknowledgment of any guilt or accountability but an act of generosity;

6. I free _________________________________, its affiliates, officers and

employees of any civil, criminal or administrative liability and waive any claims
against them from the injury I incurred.

IN TRUTH WHEREOF, I have hereunto signed this __________________ in the

_______________________.

____________________________
Affiant

Witnessed by:

__________________ _____________________

SUBSCRIBED AND SWORN to before me this _____________________ in

_________________________, the affiants exhibiting to me his/her
________________________________________.

Doc. No. _____

Page No. _____
Book No.______
Series of ______