RE C EI PT , R EL E AS E AN D Q UIT CL AIM

For v a l ue r ec e i ve d in th e am ou nt of
( __ _ _ __ _ __ _ __ _ __ _ __ 12,
__ 390.71
_ __ _ __ _ _ __ _ __ _ __ __ _ __ _ __ _ _ _ ) wh ic h was d ep os it e d in m y
B ank of t h e P hi l i p p i ne Is la n ds P a yro l l Ac c o un t , rec e ip t o f wh ic h is h er e b y
ac k no wl e dg e d, b ei n g i n f u ll a nd c om pl et e s a tis f ac t i on of a l l c l a im s I m a y h a v e or m a y
ar is e b y v ir tu e of m y em p lo ym en t wit h Optum Global Solutions, (Philippines) Inc, I,
__ _ __ _ __ _ _ __ _ __ _ __ __ A i r_a__
h _D__ a n_q_u__
e _ __ _ __ __ _ __ _ _ ________________ (Em pl o ye e
No . ______________
001713604 ) of l eg a l ag e and wi th p o s ta l ad dr es s at
B__ 4 _L__
6 _C__i t i_h_o__
me s S_u__
_ __ bd , _M__
__ o l_i n__
o _4_,__B_a_c_o_o__
r C__
i t _y __
, C_a__
v i_t e_, ha v e her eb y f or e v er
re le as ed , r em is e d a nd d is c h ar g e d, a n d b y t h es e p res e nts d o, f or m ys e lf , m y
rep res e nt at i v es , ag e nt s , as s ig ns , he irs , ex e c ut ors a n d a dm in is tr at ors , her e b y r em is e ,
re le as e a nd f or e v er d i s c har g e Optum Global Solutions, (Philippines) Inc, th e ir s u bs i di ar i es ,
s uc c es s ors , as s i g ns , an d tr us t ees a n d/ or d i rec t ors , of f ic ers , s t oc k ho l d ers , em pl o ye es ,
ag e nts a nd r e pr es e nt at i v es , of a n d f r om an y m ann er of ac t i o n or ac t io ns , c a us e or
c aus es of ac t i on , s um s of m one y, ac c ou n ts , dam ag es , c l a im s an d d em an ds
wh ats o e ve r , i n l a w or i n e q u it y, wh ic h I m a y be e nt i tl e d u n d er t h e l a w, I e v er h a d, n o w
ha v e , or h er e af t er m a y ha v e , or wh ic h m y r e pr es e n ta t i ve , a ge nts , as s ig ns , he irs ,
ex ec u tors a nd adm i n i s tr a to r s c a n, s h al l or m a y h a ve , u p on a n d b y r e as o n of , m y
em pl o ym e nt wi th Optum Global Solutions, (Philippines) Inc, or u p on an y c a us e wha ts o e v er,
i n r e la t io n or c o n n ec t i on t o m y em p lo ym e nt wi t h Optum Global Solutions, (Philippines) Inc.

I wa rra nt a nd r e pr es e nt t h at I wi ll wi t hdr a w an y pe n di n g c as e, if an y, a nd s h al l no t
i ns t it u te an d her e b y f or e ve r wa i v e al l an d an y k i nd of ac ti o n, wh et h er l e ga l ,
adm i n is tr at i v e or of a n y o t her n at ur e a n d k i nd wh a ts o e v e r wh ic h I h a d, or no w h a v e,
or her e af t er I m a y h a ve a g ai ns t Optum Global Solutions, (Philippines) Inc, t he ir
s toc k h ol d er s , of f ic er s , d ir ec t or s , tr us te es , a ge nts or em pl o ye e s ar is in g ou t of , in
c on n ec t i on wi th , r e l at ed , i nc id e nt a l or as a res u lt of m y em p lo ym ent i n Optum Global
Solutions, (Philippines) Inc.

Fi na l l y, I h er e b y u nd e r tak e in pe r p et u it y to k eep en t ire l y c onf id e n ti a l a n d t o wit h ho l d

f rom an y p ar t y a n y i nf or m at io n I h a v e rec e i ve d or m a y h a ve a c c es s t o c onc er n in g
Optum Global Solutions, (Philippines) Inc.

I c onf irm th at I r e ad a nd u n de rs t oo d t he c o nt e nts of t h is Re c e ip t, R e le as e an d

Q u itc l a im and t ha t I v o lu nt ar i l y s i gn e d t h e s am e wi ll i n gl y wi t h f ul l k no wl e d ge a n d
un d ers t a nd i n g of m y r i gh ts u nd er ex is t in g l a ws . .

J u_l y__1_2__
IN W IT NE SS W HER E O F, I h a ve h er e un to s e t m y h an d t h is _ __ , _2_0__
2 2_ _ at
T agu i g C it y.

__ _ __ _ __ A I _R_A__
H _D__
A_N__
QU__E_ __ _ __ _ _ _
Af f i a nt
(S i g na t ure o ver Pr in t ed N am e)

AC K NO W L E DG EM EN T

RE P U BL IC O F T H E P HI LI P P IN E S)
Mak a ti C i t y ) S. S.

B ef or e m e a N O T AR Y P U BL IC , p ers on a l l y ap p ea re d a nd ex am in ed ________________,
exhibiting to me his Community Tax Certificate No. __________ issued on _______________ at
_________________, and wh o c e r t if i e d t o m e th at he ex ec u te d t h is R ec e i pt , R e le as e a n d
Q u itc l a im , an d th a t ha v i ng u nd er s to o d th e s am e, it is of his f re e a nd vo l un t ar y ac t a nd
de e d.

IN W IT NES S W HERE O F, I ha v e s et m y h an d i n th e p lac e a n d da te f irs t ab o v e -

m enti o n ed .

NO T AR Y P UB LI C
Doc N o. __ _;
P ag e N o. _ _ _:
B ook N o. __ _;
S er ies of 2 0 2 0 .