REPUBLIC OF THE PHILIPPINES)

City of Sorsogon ) S.S.

x-----------------------x

AFFIDAVIT
(WAIVER OF LIABILITY OF THIRD PARTY)

I, ___________________________________, of legal age, Filipino, a

resident of ______________________________________________, Philippines,
after being sworn in accordance with law, hereby declare as follows:

1. That I am the lawful owner of the property located at

______________________ ;

2. That hazardous tree/s is/are visible on the aforementioned property

which requires immediate removal or other mitigating actions to reduce
level of risk posed to people or property as certified by the Disaster Risk
and Management Office or its authorized representatives;

3. That I am informed of the Provincial Ordinance 47-2019 otherwise known

as “Anti-Obstruction of Transmission Lines, Roads, and Public Buildings
Ordinance of the Province of Sorsogon;”

4. That I am aware that I have the primary duty and responsibility to

prevent transmission line obstructions and to inform the implementing
agency in case of their existence:

5. That I am not giving my consent to trim, prune, cut or any clearing

activities for all growing plants within the transmission line corridor
located within my territorial property;

6. That I further relieve the Provincial Government of Sorsogon or any

institution or agency/ies or any person from any liability both criminal,
civil and/or administrative brought about by my refusal to trim, prune,
cut the tree/s or any clearing activities within my territorial domain;

7. That I am consciously not giving my consent and willingly signing this

affidavit of waiver of third party liability;

8. That I am executing this Affidavit to attest to the truth of the foregoing

and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________

at _____________, Philippines.
 ________________________________
AFFIANT

SUBSCRIBED AND SWORN to before me, this ___________________, by

the Affiant who is personally known to me and who exhibited his valid ID Number
already written below his name.

NOTARY PUBLIC
Doc. No. ______;
Page No. ______;
Book No. ______;
Series of 2020.