REPUBLIC OF THE PHILIPPINES )

) SC.

AFFIDAVIT OF QUITCLAIM WITH UNDERTAKING

I, _________________________, of legal age, single/married with residence at

____________________________, under oath, do hereby depose:

That I hereby state that I have received in full the Health Emergency Allowance (HEA)
benefits under DOH AO Nos. 2022-0001-A and 2022-0039 from the Blessed Family Doctors
General Hospital (BFDGH) and hereby release said Hospital of any future claim which I may
have in relation to the aforementioned HEA;

That I hereby undertake to return any and all excess amount in full in case I receive HEA
benefits twice or more from one (1) or more health facilities;

That I execute this Affidavit to attest to the foregoing statements and for whatever legal
intents and purposes it may serve;

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

___________________.

____________________________
-Affiant-
ID No. ___________

SUBSCRIBED AND SWORN to before me this _______________at _______________.

Affiant exhibited to me a government issued ID.