REPUBLIC OF THE PHILIPPINES)

Province of Capiz
) S.S.
City of Roxas
)
x---------------x

WAIVER OF RIGHTS
OVER CAPELCO ELECTRIC METER

I, _________________, of legal age, Filipino, married and a resident

of Brgy. Lawaan, Roxas City, Capiz, after being sworn in accordance
with law, hereby declare that:
1.
I am the member-consumer of Capiz Electric Cooperative
(CAPELCO) with office address situated in Timpas, Panit-an, Capiz;
2.
That I was issued an Electric Account No. ________________
with Meter No. ______________in my said residence;
3.
That upon signing of this document, I hereby WAIVE,
RENOUNCE and CONVEY all my rights and obligation over the said
electric meter unto ______________, likewise of legal age and a resident
of ___________________who is able and willing to assume all my rights
and obligations over the said electric meter;
IN WITNESS WHEREOF, I have hereunto set my hand this
___________________ at Roxas City, Capiz, Philippines.
____________________________
Affiant
ID No: ________________________
Issued at: _____________________
SUBSCRIBED
AND
SWORN
to
before
_______________________ at Roxas City, Capiz, Philippines.

me,

this