Republic of the Philippines )

Province of ______________) S.c.

Municipality of ______________ )

AFFIDAVIT OF QUITCLAIM

I, ______________, of legal age, widow, Filipino and a resident of

______________, after having been sworn to in accordance with law, do hereby
depose and state that:

1. I am the wife of the late ______________;

2. That on ______________, a vehicular accident transpired at ______________

involving my husband, ______________, who was then driving a
______________motorcycle with side car, and ______________, who was then
driving a ______________registered under the name of ______________., that
resulted to the untimely demise of ______________;

3. That I have already entered in an amicable settlement with

______________and ______________;

4. That I hereby release, clear, and discharge ______________and

______________from any action, cause of action, sum of money, liability,
damages, claims and demands, whatsoever, which in law or in equity I have,
or which my heirs, insurer, successors and assigns hereafter may have upon
or by reason of the death of my husband;

5. That I further warrant that I will institute no further action against

______________and ______________, arising from, by reason of, or in connection
with, the aforementioned vehicular accident;

6. I executed this Affidavit in order to attest to the truth of the foregoing

circumstances, that my desistance to pursue said case is of my own free will
and volition and that there was no force, intimidation, coercion or
consideration that took place for me to make such decision.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________ at ______________.

Affiant
______________

SUBSCRIBED AND SWORN to before me this ______________at Agoo, La Union