Waiver of Rights: Subscribed and Sworn

Republic of the Philippines )
Province/City/Municipality of ____________________) S.S
WAIVER OF RIGHTS
I, NILO E. PLAZA of legal age, married, Filipino, with residence address at Purok
Centro Matiao, Mati City Province of Davao Oriental, state that:
1. On January 30, 2021 Mrs. ESTELA L. PLAZA passed away.

2. The deceased was a member of Social Security System with SSS No. 0905746508.
3. I am an heir/dependent of the deceased being her husband.
4. I have cohabited nor entered into a live-in relationship with another person before or
after the death of my spouse.
5. I hereby waive my rights in favor of my son NEIL KENNETH L. PLAZA, to claim the SSS
death benefits of my deceased spouse from SSS.
6. I hereby release and discharge the SSS from any and all liability in connection with
the
aforementioned waiver and release of the provident benefits in favor of the above
named person.
7. I am executing this affidavit to attest to the truth of the foregoing facts and
statements and to support for application for death claim from SSS.
I further sayeth not.
NILO E. PLAZA
Affiant
Witnesses:
__________________________ __________________________
Printed Name/Signature Printed Name/Signature
SUBSCRIBED AND SWORN to before me this __________ day of _________________,_____________

at _______________________________, who has satisfactory proven to me his identity through his
______________ ________________________ valid until __________________________________,
that he is the same person who personally signed before me the foregoing WAIVER of RIGHTS and
acknowledge that he executed the same.
Notary Public
Doc. No. _____________;

Page No. _____________;
Book No. _____________;
Series of _____________.
IN WITNESS WHEREOF, I
have hereunto affixed my
signature this 13
th
day
of October, 2014, in Tacloban
City, Leyte, Philippines
signature this 13
th
day
signature this 13
th
day
signature this 13
th
day
WAIVER OF RIGHTS TO
CLAIM
I, VIRGILIO G. DURAN,
of legal age, Filipino, and
resident of Brgy.
Santan, Sta. Rita, Samar, after
having been duly sworn to in
accordance with
law, hereby depose and say:
That I am the legal spouse of
the late THELMA B. DURAN
who passed away
last September 22, 2014 at the
Divine Word Hospital,
Tacloban City;
That upon her death, it
was my daughter SHIRLEE
B. DURAN-ZETA who
shouldered the funeral
expenses, since she has a
fully paid Memorial Plan
with the St. Peter Life Plan,
Inc., and had it reassigned to her
mother;
That the above-named
deceased was a member/retiree
of the Government
Service Insurance System
during her lifetime; and as
such,
Republic of the Philippines )
Province/City/Municipality of ____________________) S.S
WAIVER OF RIGHTS TO CLAIM
I, NEIL FRANCIS L. PLAZA, of legal age, Filipino, and resident of Cagayan de Oro,
after having been duly sworn to in accordance with law, hereby depose and say:
That I am the 3rd son of the late ESTELA LIMIT PLAZA who passed away last
JANUARY 30, 2021 at Purok Centro Matiao Mati City, Davao Oriental;
That upon her death, it was my older brother Mr. Neil Kenneth L. Plaza who
shouldered the funeral and burial expenses of my late mother.
That the above-named deceased was a member of Social Security System during
her lifetime; and as such, one of the benefits is the death claim.
I hereby waive all my rights and interest to claim the Death Claim Benefits of the
aforementioned deceased with SSS number 0905746508 in favor of my older
brother, NEIL KENNETH L. PLAZA;
That I execute this waiver, freely and voluntarily to attest to the foregoing facts
and statements and for whatever legal purpose this may serve.
IN WITNESS WHEREOF, I have hereunto affixed my signature this _______day of

________________,______________ at Cagayan de Oro Philippines.
NEIL FRANCIS L. PLAZA Affiant SUBSCRIBED AND SWORN to before me this

____________ day of ______________________, ________________, in Cagayan de Oro,
Philippines.
________________________
Administering Officer

Waiver of Rights: Subscribed and Sworn

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Republic of the Philippines )

Province/City/Municipality of ____________________) S.S

1. On January 30, 2021 Mrs. ESTELA L. PLAZA passed away.

death benefits of my deceased spouse from SSS.

I further sayeth not.

SUBSCRIBED AND SWORN to before me this __ day of _,_____

Doc. No. _____________;

WAIVER OF RIGHTS TO CLAIM

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______day of

NEIL FRANCIS L. PLAZA Affiant SUBSCRIBED AND SWORN to before me this

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