Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Regional Office No. ____
City/Municipality of __________, Province of ________

Name
Complainant CASE NO. 2017-

- Versus -

Name
Respondent

QUITCLAIM AND RELEASE

COMES NOW the undersigned complainant in the above entitled case

before this Office, respectfully manifest:

That for in consideration of the sum of One Million Pesos (P 1,000,000.00)

in settlement of my claim, receipt of which is hereby acknowledge to my complete
and full satisfaction. I hereby release and discharge the _____Name of
Employer________ and / or its officer, from any and all by way of unpaid wages,
separation pay, overtime pay, differential pay or otherwise as may be due me
incident to my past employment with said establishment. I hereby state further that
I have no more claim or cause of action of whatever nature whether past, present
or contingent against the said _____Name of Employer________ and/or its
officer.

In view hereof, I hereby move for dismissal of the above entitled case and
further request that the same be dropped from the business calendar of this office.

IN WITNESS WHEREOF, I hereunto set my hand this 21st day of

April 2017 at _________________, Philippines.

Name of Complainant
Complainant

PAID IN THE PRESENCE OF:

Witness 1 Witness 2
 SUBSCRIBED and SWORN TO before me this 21st day of April 2017 at
_______________, Philippines, affiant exhibiting to me her SSS ID with ID No.
______________ issued by the Social Security System, as competent evidence of
her identity, and she personally acknowledged to me that the foregoing Petition
is her free and voluntary act and deed. Machine copy of this SSS ID is hereto
attached.

Atty. Karmila D. Abogada

Notary Public

PTR No. 1234567, Iloilo City, 1/2/17

IBP OR No. 654321, Iloilo City, 1/2/17

Attorneys Roll No. 11122

MCLE Compliance Certificate No. IV-

0025415, Pasig City, 1/2/17

Doc No. _____;

Page No. _____;
Book No. _____;
Series of 2017.