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Adjudication W Waiver of Right

1) The document is a deed of adjudication with waiver of rights signed by the four children of Herminigildo Jardenico Montelijao regarding PhilHealth monetary claims after his death. 2) The children state they are waiving their rights to any PhilHealth refunds/claims in favor of their sister Rhea Montelijao-Samontanes. 3) The purpose is for Rhea to receive the full amount owed by PhilHealth regarding their late father's membership.

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Kazper Bermejo
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424 views2 pages

Adjudication W Waiver of Right

1) The document is a deed of adjudication with waiver of rights signed by the four children of Herminigildo Jardenico Montelijao regarding PhilHealth monetary claims after his death. 2) The children state they are waiving their rights to any PhilHealth refunds/claims in favor of their sister Rhea Montelijao-Samontanes. 3) The purpose is for Rhea to receive the full amount owed by PhilHealth regarding their late father's membership.

Uploaded by

Kazper Bermejo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines)

City of Iloilo ) SS
x------------------------------x

DEED OF ADJUDICATION WITH WAIVER OF RIGHTS

We, RICHARD MONTELIJAO, JOYCE MONTELIJAO- JEREZ, ROLANDO


MONTELIJAO AND RHEA MONTELIJAO- SAMONTAÑES, all of legal age, all
married, Filipino citizens and residents of Brgy Ingore, La Paz, Iloilo City, after being
sworn in accordance with law hereby depose and state:

1. That we are the children of the late HERMINIGILDO JARDENICO


MONTELIJAO, widower and a resident of Brgy. Ingore, Lapaz, Iloilo
City;
2. That HERMINIGILDO JARDENICO MONTELIJAO is a bona fide
Philippine Health Insurance (PhilHealth) Member;
3. That on December 7, 2010, our father HERMINIGILDO
JARDENICO MONTELIJAO died in West Visayas Medical Hospital,
Jaro, Iloilo City;
4. That HERMINIGILDO JARDENICO MONTELIJAO’s HEIRS are
entitled to monetary refund/ claims from the PHILHEALTH as
member thereof;
5. That WE, children of HERMINIGILDO JARDENICO
MONTELIJAO are WAIVING OUR RIGHTS on the said
PHILHEALTH’s monetary refund/ claims in favor of our sister,
RHEA MONTELIJAO- SAMONTAÑES;
6. That WE, children of HERMINIGILDO JARDENICO
MONTELIJAO are not interested / do not intend to take any share or
receive any portion of the PHILHEALTH’s monetary refund/ claims
of our late father, HERMINIGILDO JARDENICO MONTELIJAO;
7. That we are executing this Deed of Adjudication with Waiver of
Rights in order that our sister, RHEA MONTELIJAO-
SAMONTAÑES be fully paid of the total amount of PHILHEALTH’s
monetary refund/ claims due to our late father HERMINIGILDO
JARDENICO MONTELIJAO.

AFFIANTS SAYETH NAUGHT.

RICHARD MONTELIJAO JOYCE MONTELIJAO- JEREZ


______________________ __________________________

ROLANDO MONTELIJAO RHEA MONTELIJAO- SAMONTAÑES


_______________________ TIN ID NO. 945-379-129

Signed in the presence of:


_____________________ ______________________

ACKNOWLEDGMENT
REPUBLIC OF THE PHILIPPINES)
CITY OF ILOILO )S.S.
x--------------------------------------------x

BEFORE ME, a Notary Public for the City of Iloilo, on this _____ day of
___________, 2013, personally appeared the above-enumerated with their respective IDs
indicated below their names, known to me to be the same persons who executed the
foregoing instrument and they acknowledged to me that the same is their own free and
voluntary act and deed.
This instrument consists of two (2) pages, which have been signed on each and
every page by the parties and their instrumental witnesses including the page on which
this acknowledgment is written.

WITNESS MY HAND AND SEAL.

Doc. No. _____;


Page No. _____;
Book No. _____;
Series of 2013.

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