REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ ) S.S.

RELEASE, WAIVER AND QUITCLAIM,
WITH UNDERTAKING
I, ____________________, ____ years of age, Filipino, single/married, with
residence and postal address at ____________________________, after having duly
sworn to in accordance with the law, depose and state: That -1. I have a claim for payment of deposit in the total amount of P
__________________ against the assets of Unitrust Development Bank
(UDB), a closed bank under liquidation by the Philippine Deposit
Insurance Corporation (PDIC);
2. In line with the Order dated March 19, 2007 by the Regional Trial
Court of Makati City, Branch 59 (the Liquidation Court of UDB)
issued in SP. PROC. No. M-6069 entitled In re:
Petition for
Assistance in the Liquidation of the Unitrust Development Bank,
authorizing/approving the payment of my deposit claim, I hereby
acknowledge receipt from UDB, thru its Liquidator PDIC, the partial
payments of my deposit claim in check as follows:
P ____________ representing 44.4725% of my outstanding
claim paid to me on __________________ and P
______________ representing 62% of my remaining claim
of 55.5725%, or the total paid amount of P______________
out of my total outstanding deposit claim of
P_____________________;
3. To my complete and full satisfaction, I hereby RELEASE AND
DISCHARGE
UDB,
to
the
extent
of
the
amount
of
P_________________. Likewise, I hereby release PDIC, its officers,
employees, agents or representatives, from any and all liabilities
whatsoever emanating, directly or indirectly, from the claim as
partially paid; And for this purpose, I hereby hold PDIC and its
officers, employees, agents or representatives, legally free and
harmless from any and all liabilities or claims arising thereto;
4. Should UDB, or PDIC and/ or the latters officers, employees, agents
or representatives be held liable/accountable for whatever reason as
a result of such payment, I hereby agree and undertake to fully
assume the same, and shall indemnify, to the extent of the amount
of P_______________, UDB, or PDIC and/or the latters officers,
employees, agents or representatives either by refunding the same
upon demand, or indemnifying UDB or PDIC for whatever losses or
damages that may arise by reason of the foregoing payment to the
extent of the amount partially paid to me by UDB, thru its Liquidator
PDIC;
5. Finally, I hereby declare that I have fully read and understood the
contents of this document and that this Release, Waiver and
Quitclaim, with Undertaking is made freely and voluntarily, with full
knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ___ day of

______ 2013 in ________________, Philippines.
_____________________
Claimant
SUBSCRIBED AND SWORN TO before me this ___ day of ____________,
2013. The Claimant exhibited to me his/her Identification Card No. _________
issued on ____________ at ______________.
Notary Public
Doc. No. ___:
Page No. ___:
Book No. ___:
Series of 2013.