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City of Naga ) S.S.



I, _______________________________, Filipino, of legal age, (married / widow), and a

resident of ____________________________, Philippines, after being sworn to in accordance with
law, depose and state:

1. That by these presents, I hereby state that I have voluntarily resigned as ___________ of

2. That I hereby acknowledge to have received from my employer the sum of

_____________________________________ (P___________) which is in full and final
satisfaction of my salary and other benefits that may be due me for the service which I have
rendered for the latter employer;

3. That I hereby declare that I have no further claims whatsoever against my employer, its
President, members of the Board, officers or any of its staff and that I hereby release and
forever discharge all of them from any and all claims, demands, cause of action of whatever
nature arising out of my employment with the latter;

4. I further agree that this WAIVER, RELEASE AND QUITCLAIM may be pleaded in bar to any suit
or proceeding (Civil, SSS, PhilHealth, Medicare, Labor, etc.) to which either I, or my heirs and
assigns, may have against my employer in connection with my employment with the latter and
that the payment which I have received as provided herein should not in any way be construed
as an admission of liability on the part of my employer and is voluntarily accepted by me and
will, if need be, serve as full and final settlement of any amount(s) due me or any claims or
cause of action, either past, present, future, which I may have in connection with my
employment with my employer;

5. As such, I finally make manifest that I have no further claim(s) or cause of action against my
employer nor against any person(s) connected with the administration and operation of the latter
and forever release the latter from any and all liability.

6. That before I signed this document, the foregoing statements were explained to me in the
language that I understand.

IN WITNESS WHEREOF, I have hereunto set my hand this _____________ at _____________,



SUBSCRIBED AND SWORN to before me, this _____________, by the Affiant who is personally
known to me (or whom I have identified through competent evidence of identity) and who exhibited his/her
________________No. _____________ issued at _____________ on _____________.

Doc. No. ______;

Page No. ______;
Book No.______;
Series of 20____.