____ of _________ in the year 2022 in

_______________ City.

WAIVER OF RIGHTS
I, ________________, of legal age, married, and presently residing at
____________________________________, do hereby depose and state that:

1. I am the husband of ______________;

2. That I have been separated___________________________;

3. I, therefore, assent to be excluded as a beneficiary to her Financial Assistance

(Death Benefit) from the __________________________________________
and am waiving all my rights thereto;

4. By this consequence, I allow my __________,

_____________________________, of legal age, Filipino and resident of
____________________________________________, to do and execute the
following acts and things, to wit:

a. To initiate the processing of the financial assistance (death benefit) of

my wife;

b. To have all necessary documents go through any process necessary

for the approval of such financial assistance;

c. To make, execute, sign and deliver any and all papers and documents
which are necessary or essential to comply with the requirements
needed to acquire such financial assistance.

5. I have read and understood the contents thereof and the facts stated therein; and

6. I am aware that this decision of mine is irrevocable once the said financial
assistance had been released from the ___________;

In view of the foregoing, I wish to assure the (Corporation) personnel that processing the
financial assistance for the benefit of _________________ is with my blessing and in my favor as
well.

___________________
Beneficiary

ACKNOWLEGEMENT

REPUBLIC OF THE PHILIPPINES )

 ) S.S.
QUEZON CITY )

On (Month) (Day), (Year) before me, ________________________, a Notary Public,

personally appeared (Name of Principal) exhibited to me her/his Government Social Security
System I.D. with _____________________issued at Quezon City who proved to me on the basis of
satisfactory evidence to be the person whose name is subscribed to the within instrument and
acknowledged to me that he executed the same in his/her authorized capacity, and that by his
signature on the instrument the person, or the entity upon behalf of which the person acted,
executed the foregoing instrument.

WITNESS my hand and official seal at this place of Quezon City on the (Day) of (Month)
(Year).

ATTY. ______________________________
Notary public for ____________________
___________________________________
IBP no. ____________
PTR no. ____________
Roll no. ____________
MCLE no. __________
Serial no. of commission: ___________

Doc. No. __________

Page no. __________
Book no. __________
Series of 2022