For the Sole Consideration of ______________________________________________________
Dollars, $ ______________________ the receipt and sufficiency whereof is hereby acknowledged the undersigned hereby releases and forever discharges_________________________________________________________________
__________________________________________________________________________________________________
their heirs, executors, administrators, agents and assigns
and all other persons, firms or corporations liable or who might be claimed
to be liable, none of whom admit any liability to the undersigned but all
expressly deemed any liability, from any and all claims, demands, damages,
actions, causes of action or suits of any kind or nature whatsoever and
particularly on account of all damages known and unknown to property which
have resulted or may in the future develop from an accident which occurred
on or about the___________day of_________________19_______________
at or near________________________________________________________________________________________
__________________________________________________________________________________________________
Undersigned hereby declares
that the terms of this settlement have been completely read and are fully
understood and voluntarily accepted for the purpose of making a full and
final compromise adjustment and settlement of any and all claims, disputed
or otherwise on account of damages above mentioned.
Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above.
In Witness Whereof, ________________________________have hereunto set____________________hand and seal this
_________________________ day
of________________________________________19 _____________.
In presence of
(Seal)
(Seal)
(Seal)