Republic of the Philippines)

In the City of Butuan ) S.S.

AFFIDAVIT OF WAIVER

That I, _______________________________________, of legal

age, Filipino, married and a resident of _________________,
Brgy.__________________, Butuan City, Philippines, after having been duly
sworn to in accordance with the law, hereby depose and say:

That I am the lawful owner of a Residential House, constructed on the

parcel of land, owned by _________________________________, located
at _______________, Brgy. __________________, Butuan City.

That I applied for connection of water for my said residence, at Butuan

City Water District, Butuan City.

That I am aware of the terms and conditions stated in the BCWD Contract
for Water Services.

That as owner of the above mentioned Residential House, I hereby waive

and authorized Butuan City Water District to DISCONNECT my water line, if
there is complaint from the owner of the parcel of land, which my Residential
House was located.

That I am executing this affidavit to attest to the truth of my foregoing

instrument and to support for whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I hereunto set my hand this ______, day of

__________, _______ at Butuan City, Philippines,

_______________________
Affiant

SUBSCRIBED and SWORN TO BEFORE ME, this _______, day of

__________, _______ at Butuan City, Philippines.

Doc.No._________;
Page No._________;
Book No.________;
Series of_________;