Republic of the Philippines )

Angeles City ) S.S.

AFFIDAVIT OF INTENT AND QUITCLAIM

I, _____________________________________, of legal age, Filipino, married/single, with residence

and postal address at ______________________________, under oath, do hereby depose and state
that:

1. I am aware that the Retirement benefits provided by the CIAC under a

Collective Bargaining Agreement (CBA) dated 22 August 2006 is subject to a
Commission on Audit (COA), Audit Observation Memorandum No. 2014-007 (2013);

2. I am also aware of the Board Resolution No. ES-08-03, Series of 2006,

providing separation benefits to CIAC Corporate Officers (President, Executive Vice
President, Vice Presidents, Corporate Secretary and Corporate Treasurer) who are
involuntarily separated without just or authorized cause;

3. By reason of the Audit Observation Memorandum (AOM) No. 2014-007 (2012)

abovementioned, the current basis of the Retirement program of the CIAC is Republic Act
7641 (RA 7641) or the Retirement Pay Law;

4. Pursuant to RA 7641, I would like to avail of the ________________ and

request further that my retirement from CIAC be effective on _________________;

5. In the event that the Supreme Court (SC) or any competent authority affirm by
final judgment the findings of the COA, I am holding CIAC free and harmless from any
claim in connection with this retirement or arising from any employment with CIAC and
that the amount I will receive as retirement benefits shall constitute my full and entire
claim from CIAC;

6. On the other hand, should the SC or any competent authority by final

judgment, reverse the findings of the COA, the provisions of the CBA on retirement and
any amount due to me from the said CBA provisions, and the Board Resolution No. ES-
08-03, Series of 2006, providing separation benefits to CIAC Corporate Officers, shall be
paid to me, or in case of my death, to my heirs, by the CIAC, less the amounts already
paid to me under RA 7641;

7. I am executing this Affidavit of Intent and Quitclaim for the purpose of my

Retirement from CIAC and for whatever legal purpose it may serve.

AFFIANT FURTHER SAYETH NAUGHT.

NAME AND SIGNATURE OF

EMPLOYEE

SUBSCRIBED AND SWORN to before me this _________________ at Clark Freeport Zone,

Philippines, the Affiant has satisfactorily proven to me his/her identity through his/her
______________________________ and who is the same person who personally signed before me the
foregoing Affidavit of Intent and Quitclaim and acknowledged that he/she executed the same.

Doc No. ________;

Page No. ________;
Book No. ________;
Series of 2014.