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 ______________________________, 20 _____, 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 _____________________ , 20_______ .
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 _______________________, 20_____, 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.
Notary Public: _______________________________________
My Expiration Date: ___________________________, 20 ___________
.