REPUBLIC OF THE PHILIPPINES )

CITY OF TUGUEGARAO ) SS

QUIT CLAIM

KNOW ALL MEN BY THESE PRESENTS:

That I, ________________________________________, of legal age and Filipino, after

having been duly sworn to law, depose and state:

That for and in consideration of the receipt of _________________________ from

_______________________________________ I hereby expressly acknowledge the complete and full
satisfaction of the settlement of any and all claims, demands and/or actions, whether civil or criminal,
judicial or administrative that I have or may have against ______________________________;

That I have released, remised and do forever discharge and by this presents do so for
ourselves, our heirs, executors or administrators, including its employees, and personnel of and from any
and all manners of actions, cause or causes of actions, sum or sums of money, accounts, dues, damages
and demands of whatever kind and nature;

That I am executing this attestation of my own voluntary and free will without undue
influence, force or intimidation or threat being applied to me;

That I have signed these presents after having read and fully understood its contents and
all its legal implications and consequences.

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

in the year of our Lord 2017 at the Department of Health Regional Office II, Tuguegarao City.

_______________________ _______________________

SIGNED IN THE PRESENCE OF:

_________________________ __________________________

SUBSCRIBED AND SWORN to before me this _____________ day of who exhibited to me their
respective Community Tax Certificates:

ID No. Date/Place of Issue

NOTARY PUBLIC

Doc. No. : _____

Page No. :_____
Book No. :_____
Series of 2019.