REPUBLIC OF THE PHILIPPINES)

CITY OF DAVAO ) S.S.

x------------------------------------x

WAIVER
I, JOSEFA T. ROLLORATA,

of legal age, Filipino, and a resident of 101-A Candelaria

Extension, Kabacan, Matina, Davao City, after having been duly sworn to in accordance with law,
depose and state THAT:
1. I am waiving my right for reimbursement for the amount of SIX THOUSAND EIGHT HUNDRED
PESOS (P 6,800.00) as payment for the services of Angel B. Brillantes Jr. Funeral Homes, Inc. in favor
of ANTHONY TING;
2. Such payment is evidenced by a Service Contract dated December 10, 2013;
4. I am executing this affidavit to attest to the foregoing facts and for the purpose of processing the
deceaseds funeral claim application with the Social Security System.
IN WITNESS WHEREOF, we have hereunto set our hands this 20th day of December, 2013,
in Davao City, Philippines.

JOSEFA T. ROLLORATA
Affiant

SUBCRIBED

AND

SWORN

TO before

me

this ___________________ in

_________________, Philippines, affiants exhibiting to me their valid proofs of identification.

Doc. No. _____;

Page No. _____;
Book No. _____;
Series of 2013.