WAIVER OF RIGHTS

oath

of legal age, and resident/s of depose and

state:

1. That I am
the
cm.pze who died on

2. That the said decedent during his/her lifetime was a member of St. Peter Life Plan;

3. That I was / we were named and indicated as beneficiary/ies in the said St. Peter Life Plan;
4. That for expediency and convenience, I / we hereby waive any claim (Insurance,
Termination Value, Unrendered Service Benefit (One Fully Paid Plan /Continue
Installment), or Service Balance Refund, if there is any) arising from the death of over his /
her St. Peter Life Plan in favor of Mr. / Ms.

5. That I / we have voluntarily executed this waiver, without force, intimidation, fraud or
deceit upon me / us;

6. That I am / we are executing this Waiver of Rights in good faith to attest to the truthfulness
and veracity of the foregoing statements for whatever legal purpose this may serve.

IN WITNESS WHEREOF, I / we have hereunto set my / our hand and affix my / our signature this
City

AFFIANT

SUBSCRIBED AND SWORN to before me, a duly authorized notary public for and in the
abovenamed jurisdiction, on this day of 20 affiant exhibiting to me competent
evidence of identity and Community Tax Certificate ("CTC"), with details as follows:
Com etent Evidence of Identi Communi Tax Certificate
Type of ID ID Number and Number Date/ Place
Expiry Date (if a Issued
Affiant licable

Doc. No.NOTARY PUBLIC

Page No.
Book No.
Series of