REPUBLIC OF THE PHILIPPINES)

MANILA CITY ) S.S.

AFFIDAVIT OF DESISTANCE, WAIVER, RELEASE AND QUITCLAIM

I, ______________ of legal age, Filipino and a resident of ____________________ after having

been duly sworn in accordance to law, do hereby depose and say:

1. That I am a domestic helper deployed by ____ to _________ on _________, thru its accredited
principal, ___________;

2. That I caused the termination of my employment contract with my employer due to personal
reasons, and I returned in the Philippines in _________

3. That I filed a complaint at the _____________ in which a meeting was conciliated by

________________, between the representative of ________, Inc. and the undersigned and I
voluntarily agreed to settle my differences with my employer through the intercession of
________.

4. That I fully understand what happened to me in ___ and that I hereby unconditionally, knowingly
and freely release and discharge ______., its officers, and employees, as well as its foreign
principal, ____________. and my former employers in Jordan from any and all liabilities related
to the aforesaid employment and hereby voluntarily waive my rights against any and all its
officers and employees, as well as its foreign principal and my former employer;

5. That I have no further charges, claims, or demands, civil, criminal or administrative, monetary or
otherwise, about my salary against ______ and _____________, its officers and employees, and
my foreign employers;

6. I hereby further aver that I shall not file any case, or any other case whatever nature, criminal,
civil, administrative or otherwise against the said agency and agent, its officers and employees
and representatives at the PHILIPPINE OVERSEAS EMPLOYMENT ADMINISTRATION
(POEA), OVERSEAS WORKERS WELFARE ADMINISTRATION (OWWA) and other
judicial and quasi judicial bodies.

7. I am executing this affidavit to attest to the truth of the foregoing statements and is made
willingly and voluntarily, free from duress, force or intimidation and with full knowledge of my
rights under the law.

8. That I have read and fully understood the contents of this Affidavit and no fraud, force, violence
or intimidation has been employed against my person in executing the same.

AFFIANT FURTHER SAYETH NAUGHT.

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

____________________
Affiant

SUBSCRIBED AND SWORN TO before me this _________ Affiant exhibited her Passport No.
__________ issued on _____________at _____________

Doc. No.____
Page No. ____
Book No.____
Series of 2016