Palihug BLUE ballpen ang atong gamiton sa pag Fill up sa maong Porma.

Daghang Salamat.
ANNEX 2

WARRANTY AND RELEASE FROM LIABILITY

l, ________________________________, of legal age, Filipino, hereby state:

(Name of Claimant)

1. I am the (nearest relative / duly authorized representative of nearest

surviving living relatives) of the hereunder of the Social Pension for Indigent
Senior Citizens of the Department of Social Welfare and Development
(DSWD):

_______________________________
(Name of Beneficiary)

2. Said beneficiary died on __________ at

____________________________ _____________________________
(Date) (Place of Death)

3. I hereby release and agree to hold free from any responsibility and liability
the DSWD, and its officers and employees, if any other person/s should
appear and represent to be the nearest relative or duly authorized
representative of the nearest surviving living relatives of said beneficiary.

Signature over full name of claimant

Address and Contact Number

Date
Note: Please submit 1 original copy and 1 photocopy of this form when claiming the social
pension. Please use BLUE ballpen