QUITCLAIM, WAIVER AND RELEASE

I, aaaa, of legal age, (status), Filipino, and a resident of

____________________________, under oath, depose and state that:

1. I am the principal claimant in the incident that happened last October 5, 1998 at 123
Plaza, that resulted to injury to my leg (“subject incident”).

2. I have received from bbbb company the amount of FIFTEEN THOUSAND PESOS
(Php 15,000.00) to cover all the medical expenses that I incurred to treat the injury I sustained
in the subject incident.

3. For the above-stated consideration, I hereby freely, voluntarily and intelligently

release and forever discharge bbbb company., and/or its directors, stockholders, or officers, for
any matter cause, demand or damages I may have against any and or all of them, by reason of
or incidental to the subject incident.

4. I also freely understand and manifest that the payment of the foregoing consideration
shall not be taken by me, my heirs, successors or assigns as a confession and /or admission of
liability on the part of bbbb company and/or its directors, stockholders, or officers, for any matter
cause, demand or damages I may have against any and or all of them, by reason of or
incidental to any case arising from the said accident.

5. I understand that my execution of this Waiver And Quitclaim can be invoked as bar
against any claim with respect to the matters set forth herein which I may later have against
bbbb company., and/or its directors, stockholders, or officers,

6. I finally declare that I have read and fully understand the content of this Waiver And
Quitclaim which hereby being given willingly, voluntarily, and with full knowledge and
understanding of my rights under the law.

IN WITNESS WHEREOF, I hereunto set my hand this ___________________________

at ________________________________.

aaaa
Affiant

SIGNED IN THE PRESENCE OF:

______________________________ __________________________

ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINES)

___________________________ ) s.s.

BEFORE ME, a Notary Public in and for _____________________, personally

appeared Oscar M. Cruz with his Gov’t Issued ID No. __________________ issued on
_______________________ at ______________________, known to me and by me known to
be the same person who executed the foregoing Release, Waiver and Quitclaim, and who
acknowledged to me that the same is his free and voluntary act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and affix my Notarial Seal
this _____ day of __________________,20___ in __________________, Philippines.

Doc. No.______ : NOTARY PUBLIC

Page No.______ :
Book No.______ :
Series 20_______: