AFFIDAVIT with WAIVER (Heirs)

`REPUBLIC OF THE PHILIPPINES)

_________________________) S.S.

AFFIDAVIT with WAIVER

I/We, ________________________________________________________________, of legal age/s, Filipino

citizen/s and residents of ____________________________________, after having been duly sworn in
accordance with law hereby depose and state that:

1. I/we am/are the legal surviving heirs of ___________________________________, a registered

member-consumer of the Benguet Electric Cooperative, Inc. (BENECO) with the following
account/s, to wit:
__________________________ __________________________
__________________________ __________________________
2. As legal heir/s, I/we hereby waive my/our rights and obligations for the said BENECO Account/s
in favor of ______________________________________________________, who is
___________________________________________________________________.

3. I/we am/are waiving my/our rights over the above BENECO Account/s and support the
application for the Change of Account in favor of the above named on the following reasons, to
wit: ___________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.
4. I/we hereby declare that BENECO, its President, members of the Board, officers or any of its staff
shall not be held liable for any claims of ownership over the said property and BENECO Account,
that I/we hereby undertake to answer such claims, demands, cause of action of whatever
nature arising out such claims of ownership and/or approval of the application for a change of
account name;

5. I/we further agree that this WAIVER, RELEASE AND QUITCLAIM may be pleaded as bar to any suit
or proceeding to which either I/we, my/our legal heirs and assigns, may have against BENECO in
connection with the approval of the application for change of account name;

6. As such, I/we finally make manifest that I/we have no claim(s) or cause of action neither against
any employee nor against any person connected with the administration and operation of
BENECO and forever release the latter from any and all liability;

7. I/we am/are executing this affidavit to attest to the truth of the foregoing facts without any intent
to circumvent any existing laws and regulations and to comply with the requirements of BENECO
and for the legal purpose it may serve.

IN WITNESS WHEREOF, I/we hereunto set my hand this __th day of ___________, ______ at
____________________, Philippines.

_________________________
Affiant
ID No._______________________
Issued on____________________
Issued at ____________________
_________________________
Affiant
ID No._______________________
Issued on____________________
Issued at ____________________

_________________________
Affiant
ID No._______________________
Issued on____________________
Issued at ____________________
_________________________
Affiant
ID No._______________________
Issued on____________________
Issued at ____________________

SUBSCRIBED AND SWORN to before me this ___th day of ________________, in the

_______________________. Affiant/s exhibited to his/her/their Identification Card as indicated below
his/her/their names and signatures.

Doc. No. ;
Page No. ;
Book No. ;
Series of 20__.