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______________, 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 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______________________________,
20_____.
In presence of: ______________________________ Seal
____________________________________________
______________________________ Seal
____________________________________________