Republic of the Philippines )

Province of Nueva Vizcaya ) S.S.

AFFIDAVIT OF CLAIM WITH WAIVER OF RIGHTS

We, the siblings of the late ZENAIDA L. GANGAN, all of

legal age, Filipinos, after having been duly sworn in accordance with
law, depose and state under oath that:

1. We hereby declare that we are the only surviving heirs of

ZENAIDA L. GANGAN, who died last February 27, 2020, a
copy of the Certificate of Death is hereto attached as Annex
“A”.

2. We hereby waive our rights and appoint our siblings in the

person of VIRGINIA G. IMBAT and LUZ G. DACANAY, to
process, claim and execute the benefits from the OWWA of
the said late ZENAIDA L. GANGAN;

3. We are executing this Joint Affidavit to attest to the truth of

the foregoing facts and to facilitate our request. Attached
hereto our Identification as Annex “B”

FURTHER AFFIANTS SAYETH NAUGHT.

WITNESS OUR HANDS this day___of ________, _______ in

Solano, Nueva Vizcaya.

FILIPINAS G. RIVERA ROSALINDA G.

ECHEVERE
Affiant Affiant

CRUZADO L. GANGAN
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of

_____________, affiants exhibiting to me:

AFFIANT I.D. I.D. NO. VALID UNTIL

Filipinas G. Rivera PhilHealth 06-000015482-5 Lifetime
Rosalinda G. PhilHealth 06-251251061-8 Lifetime
Echevere
Cruzado L. UMID 0111-3369992-5 Lifetime
Gangan

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 20___.