Republic of the Philippines)

Province of ____________________) S.S.

City/Municipality of _____________)
x--------------x

WAIVER, RELEASE AND QUITCLAIM

I, _____________, Filipino, of legal age, ___________________ (single /

married / widow), and a resident of _____________, Philippines, after being sworn to in
accordance with law, depose and state:

1. That I hereby acknowledge to have received from _______________ (employer) the

sum of __________________________ (P_____________) as payment for my claims
against the latter for separation pay, moral, exemplary and nominal damages to which I
am entitled to pursuant to NLRC CASE NO. RAB IV 01-00108-18-L;
2. That I hereby declare that I have no further claims whatsoever against my employer,
its President, members of the Board, officers or any of its staff and that I hereby release
and forever discharge all of them from any and all claims, demands, cause of action of
whatever nature arising out of my employment with the latter;
3. I further agree that this WAIVER, RELEASE AND QUITCLAIM may be pleaded in bar
to any suit or proceeding to which either I, or my heirs and assigns, may have against
my employer in connection with my employment with the latter and that the payment
which I have received as provided herein should not in any way be construed as an
admission of liability on the part of my employer and is voluntarily accepted by me and
will, if need be, serve as full and final settlement of any amount(s) due me or any claims
or cause of action, either past, present, future, which I may have in connection with my
employment with my employer;
4. As such, I finally make manifest that I have no further claim(s) or cause of action
against my employer nor against any person(s) connected with the administration and
operation of the latter and forever release the latter from any and all liability.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at

_____________, Philippines.

Affiant
SUBSCRIBED AND SWORN to before me, this _____________, by _____________
who exhibited to me (his/her) Community Tax Certificate No. _____________ issued at
_____________, Philippines on _____________.

Notary Public
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of ______;