AFFIDAVIT with WAIVER (Current member)

REPUBLIC OF THE PHILIPPINES)

IN THE CITY OF BAGUIO) S.S.

AFFIDAVIT with WAIVER

I, ________________________________, of legal age, Filipino citizen and a resident of

_____________________________________________________________________, after having been duly
sworn in accordance with law hereby depose and state that:

1. I am registered as a member-consumer of the Benguet Electric Cooperative, Inc. (BENECO)

with the following account/s, to wit:
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________

2. I hereby waive my rights and obligations for the said BENECO Account/s in favor of
_____________________________, who is my ____________________.

3. I am waiving my rights over my 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 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, that I 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 further agree that this WAIVER, RELEASE AND QUITCLAIM may be pleaded as bar to any suit
or proceeding to which either I, my 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 finally make manifest that I 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 am 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 have hereunto set my hand this __th day of ___________, ______ at
____________________, Philippines.

_________________________
Affiant
ID No._______________________
Issued on____________________
Issued at ____________________

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

_______________________. Affiant exhibited to his/her Identification Card as indicated below his/her
name and signature.

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