Republic of the Philippines)

Province of Capiz ) S.S.

x------------------x

WAIVER OF RIGHTS

I, ______________________ of legal age, widow, Filipino, and a

resident of _______________, Philippines having been duly sworn
according to law depose and say:

1. That I am the wife of the late, ________________, a

member-consumer of Capiz Electric Cooperative, of Roxas
City, Capiz, under Account No. ____________________.

2. That being a member-consumer of CAPELCO, I received

one (1) KWH meter with Serial No._________________.

3. That, I am not longer interested to continue using the KWH

meter, thus, I hereby relinquish now all my rights over the
said KWH meter with Serial No.________________ in
favor of _________________, of legal age, and a resident
of _______________________.

4. That in this consideration, I do hereby WAIVE, CEDE, and

RELINGUISH all my rights over the said KWH meter with
Serial No.__________________, issued to my late
husband by the CAPELCO in favor of
__________________.

5. I am executing this waiver under the pain of perjury and

show that all the contents hereof are true and correct to the
best of my knowledge and the same was freely and
voluntarily entered by me.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this ___________, at _____________, Philippines.

____________________
Affiant

Signed in the Presence of:

_________________________ ________________________

SUBSCRIBED AND SWORN to before me this ___________, at

Roxas City, Capiz, Philippines, affiant personally appeared with his valid
Identification Card No. ______________.

Doc No._______
Page No. ______
Book No. ______
Series of 2023.