KNOW ALL MEN BY THESE PRESENTS:

That we, ______________________________________________ and ___________________________________
                                    (Husband)                                                                                                    (Wife)
husband and wife, residing at _____________________________________________________________________

and each being of  lawful age, for the sole consideration of _______________________________________________

_______________________________________________________________________dollars ($_____________)

to be paid  to _____________________________________________  have remised, released, and forever discharged
and by these presents do, severally and jointly, for ourselves and for our heirs, executors, administrators, and

assigns, do by remise,  release, and forever discharge ___________________________________________________

____________________________________________________________________________________________
and his, her, their, and its successors arid assigns, and each of their heirs, executors, and administrators, and all other Persons, firms, and corporations, of and from any and all  Claims, demands, rights, and causes of action, of whatsoever kind or nature, arising from or by reason of any and all known and unknown., foreseen and unforeseen bodily and personal

injuries, loss arid damage to property, and the consequences thereof, resulting, and to result, from a _________________

which happened on or about the ____________________________ day  of _________________19________ at or near

_____________________________________________________________________________________________
It is further understood and agreed that this settlement is the compromise of doubtful and disputed claims, and that the payments are not to be construed as an admission of liability on the part of ____________________________________

__________________________________________ by whom liability is expressly, denied.
This release contains the ENTIRE AGREEMENT between the parties hereto, and the terms of this release are contractual and riot a more recital.
We further state that we have carefully read the foregoing release and know the contents thereof, and we sign the same as our own free acts.

WITNESS our hands and seals this ____________________day of____________________________ , 19 _________.
SIGNED IN THE PRESENCE OF                                                      CAUTION: READ BEFORE SIGNING
_______________________________________________

_______________________________________________ _______________________________________(SEAL)

_______________________________________________ _______________________________________(SEAL)

_______________________________________________

State of ______________________________________

County of ____________________________________
On the _________________________ day of __________________________19_______ before me personally  appeared
______________________________________________a n d ____________________________________________ to me known to be the persons who signed the foregoing release, and after I had fully explained to them the nature and legal effect thereof acknowledged that they fully understand its contents and meaning and duly executed the some as their free act and deed and for the sole consideration tlierein expressed.
 IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my notarial seal on the day and year first above
written.
                                                                                      __________________________________________________
                                                                                                                                        Notary Public

My commission expires ___________________________________________

 (If this release is acknowledged before a Notary Public, no witnesses' signatures are necessary.)

FORM NO. GEN HUSB/WIFE
OHIO ADJUSTER'S DIRECTORY
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