Republic of the Philippines DEPARTMENT OF LABOR AND EMPLOYMENT Regional Office No.

02 Tuguegarao City, Cagayan

________________________ Complainant/s

CASE NO. ______________________

Versus -

________________________ Respondent/s QUITCLAIM AND RELEASE COMES NOW the undersigned complainant in the above entitled case before this Office, respectfully manifest: That for in consideration of the sum of ________________________________________ (P ____________) in settlement of my / our claim; as financial assistance and / or gratuitously given by my / our employer, receipt of which is hereby acknowledge to my / our complete and full satisfaction. I / we hereby release and discharge the _______________________ and / or its officer, from any and all by way of unpaid wages, separation pay, overtime pay, differential pay or otherwise as may be due me/us incident to my/our past employment with said establishment. I/We hereby state further that I/We have no more claim or cause of action of whatever nature whether past, present or contingent against the said ____________________ and/or its officer. In view hereof, I/We hereby move for dismissal of the above entitle case and further request that the same dropped from the business calendar of this office.

IN WITNESS WHEREOF, I/We hereunto set my/our hand/s this _________day of ____________ at _____________. ________________________ Complainant/s PAID IN THE PRESENCE OF: ______________________________ __________________________

SUBSCRIBED AND SWORN to before me this ______________, day of ______________ at _________________.