Affidavit of Quitclaim With Undertaking
Affidavit of Quitclaim With Undertaking
Affidavit of Quitclaim With Undertaking
) SC.
That I hereby state that I have received in full the Health Emergency Allowance (HEA)
benefits under DOH AO Nos. 2022-0001-A and 2022-0039 from the Blessed Family Doctors
General Hospital (BFDGH) and hereby release said Hospital of any future claim which I may
have in relation to the aforementioned HEA;
That I hereby undertake to return any and all excess amount in full in case I receive HEA
benefits twice or more from one (1) or more health facilities;
That I execute this Affidavit to attest to the foregoing statements and for whatever legal
intents and purposes it may serve;
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-Affiant-
ID No. ___________