REPUBLIC OF THE PHILIPPINES )
___________________________ ) S.S.
AFFIDAVIT OF WAIVER
I, Claudine D. Dela Cruz, of legal age, single/married, Filipino, and resident of Phase 3
Package 3 Blk 78 Lot 27 Munting Nayon Bagong Silang Brgy. 176 Caloocan City, after having
been duly sworn to in accordance with, hereby depose and say:
I’m one of the legal heirs of my late father, Javier C. Dela Cruz who died on November
10, 2020.
As legal heirs of the deceased and for reasons of gratuity and generosity, we hereby
WAIVE whatever share, interests or rights we may have in the proceeds of the account/s of my
late father Javier C. Dela Cruz in Paramount Life and General Insurance with PN 353407 in
favor of my mother Cecilia D. Dela Cruz likewise of legal age, single/married, and
residence of Phase 3 Package 3 Blk 78 Lot 27 Munting Nayon Bagong Silang Brgy. 176
Caloocan City;
I understand that this waiver is voluntary and that I am under no compulsion to sign this
waiver. I also understand that by signing this waiver, I am forever giving up any and all rights
that I may have as a beneficiary under the policy and that I will not be able to change my mind
and revoke this waiver at any time in the future.
I executed this waiver before a notary public to attest to these facts and statements and
for any legal purposes.
IN WITNESS WHEREOF, I have hereunto set my hand this ______ day of
_____________ at ____________________, Philippines.
_________________________ _________________________
Name of Heir Mother of Heir
SIGNED IN THE PRESENCE OF:
_________________________ _________________________
SUBSCRIBED AND SWORN TO BEFORE ME, a Notary Public for and in
______________________ this ______ day of _______________ 200 ___, affiant
exhibiting to me his/her Community Tax Certificate No. _______________, issued on
_________________, at ___________________, Philippines.
NOTARY PUBLIC
Doc. No. _____
Book No. _____
Page No. _____
Series of 200__
