Republic of the Philippines)

City of __________________) S.S.

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

AFFIDAVIT OF QUITCLAIM AND RELEASE

I, ROWENA QUINTO Y GUINTO, of legal age, Filipino, widower, and a

resident of Marseilla St Brgy Ligtong III, Rosario, Cavite, after having been sworn in
accordance with law, hereby depose and state:

1. That I am the victim in an accident that transpired on October 27, 2023 at

Marseilla St Brgy. Bagbag 1, Rosario, Cavite, in front of Flex Fuel, was
accidentally hit and bumped by a certain Mazda CX-5 AWD SPORT, color
silver, with plate no. NEW 7610 , being driven by Alfie Basa Cawas;

2. That by reason of said unexpected incident, I was given medical care and
assistance at Divine Grace Hospital;

3. That Alfie Basa Cawas assisted and shouldered all the expenses incurred
for my treatment, operation, and medications in the amount of
Php._________________, representing all the cost for treatment and
recovery in its entirety;

4. That due to the foregoing, I hereby discharge and forever release Alfie
Basa Cawas of any and all whatever claims, whether civilly (monetary or
otherwise) criminally or administratively;

5. That I hereby further state that I have no more claims, whether past,
present or future against me and Alfie Basa Cawas;

6. That I have voluntarily executed this statement, after the contents thereof
were explained a language understood by me and in the presence of
witnesses, to attest to the truth of the above and for all legal intents and
purpose.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of

__________________ at _______________, Philippines.

ROWENA GUINTO QUINTO

Affiant

Witness:
____________________________ ______________________________

SUBSCRIBED AND SWORN TO BEFORE ME, this ____ day of

__________________ at ______________, Philippines.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 2023.