Republic of the Philippines )

MUNICIPALITY OF STO. TOMAS)S.S.

Province of Davao del Norte )
x--------------------------------------x

AFFIDAVIT
(WAIVER/TRANSFER OF RIGHTS)

We, GIOVANNIE D. DANO and REY ANNE D. DANO, both of legal age,
Filipinos, single, and residents of San Jose, Sto. Tomas, Davao del Norte,
Philippines, after having been sworn to in accordance with law, do hereby
depose and state:

1. That we are the same affiants who personally and voluntarily caused
the preparation of this affidavit;

2. That we are the surviving heirs and children of the late German O.
Dano, who died on December 13, 2008 at Davao Regional Hospital,
Apokon, Tagum City;

3. That likewise our father is a member of the Philippine Health

Insurance Corporation (Philhealth) with Phil. Health I.D No. 16-
200204400-5 ;

4. That we hereby waive our rights on whatever claims from the Health
Insurance Corporation relative to the death of our father, German O.
Dano, in favor of our mother, ANNA D. DANO;

5. That we are executing this affidavit to attest the veracity of the

foregoing declarations and for whatever legal purpose this may serve
best.

IN WITNESS WHEREOF, I have hereunto set my hand this

___________________ at Sto. Tomas, Davao del Norte, Philippines.

GIOVANNIE D. DANO REY ANNE D. DANO

Affiant Affiant
CTC No.04918346 CTC No.04918345
Issued on 01-19-09 Issued on01-19-09
Issued at San Jose, Sto. Tomas Issued at San Jose, Sto. Tomas

SUBSCRIBED AND SWORN to before me this ______________________ at

Sto. Tomas, Davao del Norte, Philippines.

Doc. No.__________;
Page No.__________;
Book No.__________;
Series of 2009.