Republic of the Philippines }

City of _______________ }

ACKNOWLEDGEMENT RECEIPT
- with -
RELEASE, WAIVER, AND QUITCLAIM

I, _________________, a Filipino, of legal age, with postal address at

______________________________hereinafter referred to as the “First Party”, after hereby
being duly sworn, do hereby states under oath that:
1. First Party has offered to remise, release, and forever discharge, as well as waive any
action(s), cause(s) of action, sum(s) of money, account(s), damage(s), loss(es),
claim(s), demand(s) whatsoever it may have against ______________________
arising out of or in connection with the damage resulting from the bounced checks
issued in favor of First party, for and in consideration of ____________________
PESOS (Php __________; the “Settlement Offer”) as the complete and final
amount owing to First Party for the damage caused, and which amount has been duly
received and accepted by me.

2. In consideration of the payment by ______ of the Settlement Offer, I hereby remise,

release, and forever discharge, and by these presents do, for itself, and its successors-
in-interest, _____, including all its directors, officers, employees, counsel, and agents
from any and all liabilities arising out of or in connection with the above-mentioned
incident.

3. Further, the I hereby waives action(s), cause(s) of action, sum(s) of money, account(s),
damage(s), loss(es), claim(s), demand(s) whatsoever, against ______ and _______,
including all its directors, officers, employees, counsel, agents, and driver, from any and
all liabilities arising out of or in connection with the above-mentioned incident.

4. In addition, I hereby holds _______ and _______, including all its directors, officers,
employees, counsel, agents, and driver, free and harmless from any and all action(s),
cause(s) of action, sum(s) of money, account(s), damage(s), loss(es), claim(s),
demand(s), and liability(ies) whatsoever, that it, or its successors-in-interest, may incur
arising out of or in connection with the above-mentioned incident.

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

________________ in ________________.

____________________

ACKNOWLEDGEMENT

1
 SUBSCRIBED AND SWORN TO BEFORE ME, a notary for and in the City of
________________, personally appeared the following exhibiting his evidence of competent
identity:

EVIDENCE OF COMPETENT IDENTITY

COMPLETE NAME
(ID)

known to me and to me known to be the same persons who executed the foregoing
Acknowledgement with Release, Waiver, and Quitclaim and he acknowledged to me that the
same is his free and voluntary act and deed, and that he is respectively authorized and capacitated
to do so for the firm that he represents.

WITNESS MY HAND AND SEAL, on the date and place first above written.

Notary Public
Doc. No.______;
Page No. ______;
Book No.______;
Series of 2018