PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN

(GOVERNMENT SERVICE INSURANCE SYSTEM)

Financial Center, Macapagal Boulevard, Pasay City

REFERENCE NO. :

RELEASE OF CLAIM AND SUBROGATION RECIEPT

FOR THE SOLE CONSIDERATION OF PESOS: Fourteen Thousand Eight Hundred Five
Pesos Only (Php 14,805.00) the receipt of which is hereby acknowledged, I/We Jennifer C. Bretaña for
myself/ourselves, heirs Representatives , successors and assignee, do hereby release and discharge
Government Service Insurance System from all actions, claims, demands and rights of action
whatsoever that may exist or may hereafter develop and particularly on account of all known, unknown,
and unanticipated injuries, damages and/or losses arising out of an as a consequence of an accident that
occurred on or about January 27, 2023 at Crossing Abad Santos, Brgy. Zone III, City of Koronadal .

I/We further agree that this Release may be pleaded against me/us to any suit or proceedings
which I/We, or anyone on my behalf, may have taken or may take in connections with this accident; that
his payment or service is not an admission of liability by the party/ies hereby released and is voluntarily
accepted in full and final compromise and settlement of the claim.

It is further agreed that Government Service Insurance System is hereby subrogated to all
rights of recovery by the undersigned on all the aforesaid claims, demands and rights of all actions from
whomsoever may be liable therefore, and is hereby authorized to institute whatever legal proceedings
necessary for the endorsement thereof, and to present compromise or withdraw the same, in the name of
the undersigned or in its name.

I/We manifest, that the term of this release have been read and/or translated to me in English, a
dialect known to me and that I fully understand the content and import of the same.

IN WITNESS WHEREOF, ________________________ have ser his/her hand this

_______________.

WITNESSES JENNIFER C. BRETAÑA,EnP

PLEASE SIGN OVER PRINTED NAME
MA. ESTELA M. TAN Comm. Tax No. ID No. R12-001

Issued at Quezon City

APRIL JOY F. BORERES On January 01, 2021

REPUBLIC OF THE PHILIPPINES)

City of Koronadal, South Cotabato )S.S.

Personally appeared before me at __________, Philippines this ____ day of __________ with Community
Tax No. __________ issued at _________ on ______________ who executed the above Release and he/she
acknowledge that the same is his/her free act and deed and I certify that before the execution thereof I have read and
explained to him/her the contents and import thereof and he/she declared before execution of said Release that
he/she fully understood the same.

WITNESS MY HAND AND SEAL OF MY OFFICE.

NOTARY PUBLIC