REPUBLIC OF THE PHILIPPINES)

PROVINCE OF SURIGAO DEL SUR) S.S

WAIVER
KNOW ALL MEN BY THESE PRESENTS:

I, ABCDE FGHIJ KLMNO, Filipino, of legal age and a resident of P-6, Goma,
San Tita, Kigwa City, Koto del Sur, after having been duly sworn to in accordance
with law, hereby depose and state, THAT:

1. I am presently occupying a government-owned lot (a timberland) at

P-6, Goma, San Tita, Koto City.

2. I am applying for electricity connection before the DURSECO.

3. Considering that I am not the actual owner of the lot where my

house is situated, I am executing this waiver in lieu of the
requirements for electricity connection.

4. I agree and promise that I will peacefully vacate the lot whenever the
city government use it in the future.

5. I execute this affidavit to attest to the truth of the foregoing and

whatever legal purposes it may serve best.

IN WITNESS WHEREOF, I have here unto set my hand this 14 th day of May
2023 in the City of Kigwa, Province of Koto del Sur.

ABCDE FGHIJ KLMNO

Affiant
ID No.: PhilHealth (12-000000591-6)

SUBSCRIBED AND SWORN to before me on the date and place first above
written.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2023.