RELEASE, WAIVER

and QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

I, CHARLYN A. FERNANDEZ, of legal age, married, Filipino, and with residential

address at Habitat, Pamplona, Negros Oriental, after having been duly sworn to in accordance
with law, do hereby depose and state that:

1. I hereby acknowledge the receipt of THIRTEEN THOUSAND ONE HUNDRED

EIGHTY-SIX PESOS and SEVENTY-FIVE CENTAVOS (the “Consideration”) from
WILMA B. MAGBULOGTONG, (a breakdown of the expenses and corresponding
receipts are herein attached);

2. I acknowledge the sufficiency of the Consideration as the sole consideration for this
Release, Waiver and Quitclaim;

3. I voluntarily accept the Consideration for the purpose of creating a full and final
settlement of any and all claims for any losses, damages, injuries or otherwise that have
arisen out of the accident involving me and the son of Wilma B. Magbulogtong, namely
James Clark B. Magbulogtong last November 18, 2020, which led to my hospitalization
from November 18, 2020 to November 26, 2020;

4. In view of the receipt of the Consideration, I hereby quitclaim, release, waive and
discharge, forever and unconditionally, Wilma B. Magbulogtong and her son James Clark
B. Magbulogtong, and/or their agents, representatives, and successors-in-interest from
any and all causes of actions, sums of money, claims, damages, demands and any further
liability in law, contract, and equity – past, present or contingent – which I, or my
successors-in-interest, representatives, and assigns had, have or may have against Wilma
B. Magbulogtong and James Clark B. Magbulogtong, their agents, assigns or
representatives in connection to the abovementioned accident;

5. I shall not file or cause to be filed any legal action or complaint in connection with or
arising from the abovementioned accident in any office, board, bureau, court, tribunal,
and agency against Wilma B. Magbulogtong and James Clark B. Magbulogtong, their
agents, assigns or representatives. Any and all actions in connection with or arising from
the abovementioned accident already commenced either solely in my name or jointly
with others against Wilma B. Magbulogtong and James Clark B. Magbulogtong, are
hereby deemed voluntarily withdrawn and I or any of my successors-in-interest,
representatives and assigns will no longer participate, testify, prosecute or provide any
evidence in said action;

6. I shall likewise not participate, testify, provide any evidence, or in any way, assist in any
and all actions or complaints in connection with abovementioned accident;

In witness whereof, I have hereunto set my hands, this _________ day of _____________,
2020 at _________________.

CHARLYN A. FERNANDEZ
Affiant
Release, Waiver and Quitclaim_Charlyn Fernandez
Page 2 of 2

Proof of Identity:
I.D. No.:

Signed in the Presence of:

_______________________ _________________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

)  SS.

BEFORE ME, a Notary Public, personally appeared abovementioned Affiant and exhibited to
me his/her competent proof of identity as indicated below his/her name. Known to me to be the
same person who executed the foregoing instrument and acknowledged to me that the same is
his/her free act and voluntary deed.
 
This instrument, consisting of TWO (2) pages, including the page on which this
acknowledgment is written, has been signed on the left margin of each and every page thereof
by the concerned parties and their witnesses, and sealed with my notarial seal.
 
WITNESS MY HAND AND SEAL on this ___day of __________________20__ at Dumaguete
City.

Doc No.:
Page No.:
Book No.:
Series of 2020.