Republic of the Philippines

____________________

RELEASE, WAIVER AND QUITCLAIM

I, _____________________________, of legal age, Filipino, presently residing at
____________________________ after having been duly sworn to in accordance with law, do
hereby depose and state that:
1. I am one of the claimants of ONE COVID ALLOWANCE (OCA) benefit. I understand and
agree if in case we receive OCA benefits twice or more from one or more health facilities, we
shall return the excess amount.

IN WITNESS WHEREOF, we executed this instrument this _____ day of _____________

2022 at Ligao City, Albay, Philippines.

_____________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME this ______ day of ______ 2022 in

__________________, affiant, __________________________ personally appeared before me and
issued on _________________ at ________________________.
Witness my hand and seal this ______ day of __________ 2022.

NOTARY PUBLIC
Doc. No._____:
Page No.____:
Book No.____:
Series of 2022