DEED OF RELEASE, WAIVER AND QUITCLAIM

I, ______________________, both of legal ages, Filipinos, and

residents of ________________________________________, Philippines,
hereby DECLARE AND MANIFEST:

That for and in consideration of the amount of

__________________________________________ (P_____________) in
cash, in hand received by us to our full and complete satisfaction, and the
payment and settlement by ____________________ of the hospital and
medical bills and expenses he incurred for injuries sustained by me, I, hereby
absolutely release, completely clear, and forever discharge the said
____________________ from any action, cause of action, sum of money,
liability, damages, claims and demands whatsoever, which in law or in equity
I have, or which I, my heirs, insurer, representative, successors and assigns
hereafter may have upon or by reason of the injuries sustained by me, which
happened on _____________ at _____________ involving the motor vehicle
with Plate No. _____________ owned by the said
_______________________ with the intention to completely and absolutely
waive all our right of action, causes of action, claims and demands, of
whatever nature, arising from, or in connection with the aforementioned
accident.

I further warrant that I will institute no further action against the said
_____________ arising from, by reason of, or in connection with, the
aforementioned vehicular accident. I also manifest that the said payment /
settlement made by the said _______________________ shall not be taken
by me, my heirs, my insurer or assigns, as a confession and/or admission of
liability on the part of the said ______________________ in connection with
the aforementioned accident.

IN WITNESS WHEREOF, we have hereunto set our hands this

_____________ at _____________, Philippines.

AFFIANT

SIGNED IN THE PRESENCE OF:

______________________ ______________________