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Waiver: I, JOSEFA T. ROLLORATA, of Legal Age, Filipino, and A Resident of 101-A Candelaria

Josefa T. Rollorata waived her right to reimbursement of 6,800 pesos for funeral services provided by Angel B. Brillantes Jr. Funeral Homes, Inc. for Anthony Ting. This waiver was made in a service contract dated December 10, 2013. Josefa executed an affidavit on December 20, 2013 in Davao City to attest to waiving reimbursement in order to process Anthony Ting's funeral claim application with the Social Security System.

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248 views1 page

Waiver: I, JOSEFA T. ROLLORATA, of Legal Age, Filipino, and A Resident of 101-A Candelaria

Josefa T. Rollorata waived her right to reimbursement of 6,800 pesos for funeral services provided by Angel B. Brillantes Jr. Funeral Homes, Inc. for Anthony Ting. This waiver was made in a service contract dated December 10, 2013. Josefa executed an affidavit on December 20, 2013 in Davao City to attest to waiving reimbursement in order to process Anthony Ting's funeral claim application with the Social Security System.

Uploaded by

bubblingbrook
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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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.

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