REPUBLIC OF THE PHILIPPINES)

CITY OF BACOLOD ) S. S.
x-------------------------------------------x

WAIVER OF RIGHTS AND/OR AFFIDAVIT OF DESISTANCE

I, RENE B. ARCENAL, of legal age, Filipino, single and a resident of Purok Ipil-ipil, Brgy.
Calumangan, City of Bago, Negros Occidental, Philippines, under oath hereby depose and say:

That I am the victim of an incident that occurred on August 13, 2015 at around 5:00 PM at the
national highway of Brgy. Calumangan, Bago City;

That together with Mr. Garry Ambong, we were riding a Rouser 125 motorcycle, with
temporary plate no. 063010 when we accidentally hit the sagging secondary electrical wire of
CENECO traversing the said highway;

That as a result of the above-mentioned incident, I was immediately brought to Bago City
Hospital for medical treatment;

That CENECO shouldered and paid my X-ray, medicine, medical expenses along with the
damages that my motorcycle incurred in the total amount of One Thousand One Hundred Eighty One
and Eighty Centavos (P1,181.80);

That aside from the hospitalization bills/medical expenses, CENECO likewise extended me
financial assistance in the amount of Two Thousand Two Hundred Pesos (P2,200.00) to cover for the
loss of my income for (14) days and other incidental expenses;

That I hereby WAIVE, RENOUNCE and FOREGO, whatever claim and/or claims that I may
have in the future against (CENECO), its staff, officers and employees either civilly or criminally
acknowledging the said incident was purely accidental;

That in executing this affidavit, I was not tricked nor forced by CENECO or by any of its
representatives or officers and that under oath, this quitclaim may be pleaded to bar any claims or
proceedings which may have been taken in connection with this said incident;

IN WITNESS WHEREOF, I have hereunto set my signature this _____ day of ________ 2015
at the City of Bacolod, Philippines.

RENE B. ARCENAL
Affiant

WITNESSES:

_____________________________ ____________________________

ACKNOWLEDGEMENT

SUBSCRIBED AND SWORN to before me this _______ day of _________________ 2015 at

the City of Bacolod, Philippines. Affiant personally appeared before me and exhibit to me his
competent proof of identity below his name.
NOTARY PUBLIC

Doc. No. _________;

Page No. _________;
Book No. _________;
Series of 2015.