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 but expressly deemed any liability from all claims in reference to bodily injury demands, damages actions, causes  of action or suits of any kind or nature whatsoever and particularly on account of all injuries known and unknown both to person 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 the injuries above mentioned and for the express purpose of precluding forever any further or additional claims arising out the aforesaid accident.

Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above.
 

IN Witness Whereof of,__________________________have hereto set______hand and seal this_________day of_____________________________________19_____.
 

In presence of:         ______________________________      Seal

____________________________________________   ______________________________ Seal
____________________________________________