RELEASE FORM

(Third Party Personal Injury & Property Damage)

WITHOUT PREJUDCE OR ADMISSION OF LIABILITY

Date of Occurrence: 16th September 2016

Claim No: Our reference: Garden Cities
In accepting this offer in the sum of R5700.00 (Five Thousand Seven Hundred
Rand only, I/We Danielle Schoeman hereby release and forever discharge for
myself/ourselves my/our heirs, executors, administrators and assigns, Garden Cities, Agents and
its Contractors of and from all claims, demands, damages, actions, causes of action, or suits of
law or in equity of whatsoever kind or nature, for or because of any matter of thing done, omitted
or suffered to be done by Garden Cities, Agents and its Contractors prior to and including the
date hereof, and particularly on account of all injuries, both to person and property, resulting or to
result from an accident that occurred on 16th September 2016. I further acknowledge that this
offer is made without prejudice and without admission of liability.
I/We hereby acknowledge that I/We have not induced to sign this release by any representations
whatsoever made to me by any person or persons and that I/We will not be entitled to
cancelation of this settlement on any grounds whatsoever.
Furthermore, this offer is merely made to resolve this matter in an amicable manner without
admission of accepting liability and in full and final settlement in respect of this matter.
The rights of Garden Cities, Agents and its Contractors are reserved herein.

Signed at..on this the.day of . 2016

in the presence of the undersigned witnesses.

Claimant
Danielle Schoeman

Witness(1)
Name:

Signature

Witness (2)
Name:

Signature