RELEASE IN FULL
FOR THE SOLE AND ONLY CONSIDERATION OF
...............................................................................................................................................................................................................................................(Dollars)

( $---------------------------- ) to me/us paid, receipt of which is hereby acknowledged, I/we hereby release and discharge _________________________________________________________

______________________________________________________________________________________________________________________________________________________
his or their successors and assigns, and all persons, firms or corporations who are or might be vicariously liable, from all claims of any kind or character, specifically including any claim for contribution or indemnity, which I/we have or might have against him or them, and especially because of all damages, losses or injuries to person or property, or both, whether developed or undeveloped or known or unknown, resulting or to result from accident on or about ________________,  20______,
at ______________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________
and I/we hereby acknowledge full settlement and satisfaction of all claims, demands, actions and causes of action of whatsoever kind or character which I/we may have against him or them by reason of the above mentioned damages, losses or injuries.
 I/we have represented that the injuries sustained are permanent and progressive and that recovery therefrom is uncertain and indefinite, and in making this release and agreement, it is understood and agreed that I/we rely wholly upon my/our own judgment, belief and knowledge of the nature, extent and duration of said injuries and that no representations or statements regarding said injuries or regarding any other matters made by the persons, firms or corporations who are hereby released or any other person or persons representing him or them or by any physician or surgeon by him or them employed has influenced me/us to any extent whatever in making this release.
 It is further understood and agreed that the payment of said amount is not to be construed as an admission of liability upon the part of said persons, firms or corporations; liability being by him or them expressly denied.
 All agreements and understandings between the parties hereto are embodied and expressed herein and the terms of this release are contractual and not a mere recital.

I /We Have Read the Foregoing Release and Fully Understand It
 
Signed, sealed and delivered this _________ day of _____________________,  20_______. 
 In the presence of:                                                                  (Claimants sign below)

____________________________________________ ______________________________________________(Seal)

____________________________________________ ______________________________________________(Seal)

____________________________________________ ______________________________________________(Seal)

IMPORTANT

Do you understand that by executing and delivering the foregoing release and accepting the money paid you therefor, that you thereby release all claims for injuries and damages which you now or hereafter may have against those released and whether or not they are presently developed or undeveloped or presently known or unknown?        __________    ____________
                                                                                                                                       Yes                           No

 ___________________________________________________  (Seal)

___________________________________________________  (Seal)

___________________________________________________  (Seal)
   (Claimants sign above)


 STATE OF Ss:  _____________________

COUNTY OF:   _____________________ 

On this _____day of ____________________,  20______,  before me personally came__________________________ to me known and known to me to be the person described in and who

executed the within instrument, and who duly acknowledged to me that (Executed the same of own free will and accord, and that before such execution the various provisions thereof had been

specifically called to attention and explained to and that fully understands each and everyone of them, including the paragraph marked IMPORTANT.

_____________________________________ Notary Public

 ____________________________________  Expiration Date:


4-C-119