WAIVER OF RIGHTS AND INTEREST

KNOW ALL MEN BY THESE PRESENTS:

We of legal ages, Filipino citizens and a resident

of , as heirs of and beneficiaries in Fortune Life Insurance Co.,

Inc. of the late , our daughter, do these presents,

hereby waive any all of our rights, titles and interest therein as such beneficiaries

therein favor of our son in law, .

By this Waiver of Rights and Interest, We hereby authorize Fortune Life

Insurance Com., Inc. to issue the check/s in payment for the proceeds to and in the

name of our son in law, .

Beneficiary Beneficiary Beneficiary

ID No:_______________ ID No: ______________ ID No.: _____________
Issued on:____________ Issued on:____________ Issued on:___________
Issued at:_____________ Issued at: ____________ Issued at:____________

BEFORE ME, a Notary Public for and in the , this __ day of

_________________, personally appeared the parties with above Identification who is known

to me to be the same person who executed the foregoing instrument and he acknowledge to me

that the same is at his own free and voluntary act and deed.

WITNESS MY HAND AND NOTARIAL SEAL.

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