KNOW ALL MEN BY THESE PRESENTS:

                                                                                                                                                                       That the Undersigned, being of lawful age, for sole consideration
of ____________________________________________________________________________________________________________________________Dollars   ($ _______________ )
to be paid to _____________________________________________________________________________________________________________________________________________,

do/does hereby and for my/our/its heirs, executors, administrators, successors and assigns release, acquit and forever discharge ___________________________________________________
________________________________________________________________________________________________________________________________________________________
and his, her, their, or its agents, servants, successors, heirs, executors, administrators and all other persons, firms, corporations, associations or partnerships of and from any and all claims, actions, causes of actions, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever, which the unsigned now has/have or which may hereafter accrue on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen personal injuries and property damage and the consequences thereof resulting or to result from the occurrence on or about the ___________________ day of ______________________________, 19 _____, at or near __________________________________________________
________________________________________________________________________________________________________________________________________________________
  It is understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that the payment made is not to be construed as a admission of liability on the part of the party or parties hereby released, and payment made is not to be construed as an admission of liability on the part of the party or parties hereby released, and that said releasees deny liability therefor and intend mostly to avoid litigation and buy their peace.
 The undersigned hereby declare(s) and represent (s) that the injuries sustained are or may be permanent and progressive and that recovery therefrom is uncertain and indefinite and in making this Release it is understood and agreed, that the undersigned rely (ies) wholly upon the undersigned's judgment, belief and knowledge of the nature, extent, effect and duration of said injuries and liability therefor and is made without reliance upon any statement or representation of the party or parties hereby released of or their representatives or by any physician or surgeon by them employed.
 In further consideration of the above payment, the undersigned hereby agrees to save harmless and indemnify the party or parties hereby released of and from any and all expense arising because of any claim which may hereafter be presented by anyone for loss and damage or personal injury as a result of the above mentioned occurrence.

THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND INDEMNITY AGREEMENT AND FULLY UNDERSTANDS IT.

Signed, sealed and delivered this___________day of _____________________ , 19_______ .

 CAUTION: READ BEFORE SIGNING BELOW

____________________________________                                                         ___________________________________LS
                                Witness
____________________________________                                                         ___________________________________LS
                                Witness
____________________________________                                                         ___________________________________L S
                                Witness
 

ST A T E 0 F ____________________________
                                                                                            SS.
COUNTY OF ___________________________

On the _____________ day of _______________________ 19_____, before me personally appeared ______________________________ __________________________________________________________________________________________________________________

to me known to be the person(s) named herein and who executed the foregoing Release and ___________________________acknowledged to me that _____________ voluntarily executed the some.

My term expires ___________________________ 19 ____________ . ________________________________________
                                                                                                                                                              Notary Public