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_________________, 20_______________
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________________________________________, 20 _____________.
In presence
of
(Seal)
(Seal)
(Seal)