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I, __________, of legal age, , and resident of _____________,

Philippines, hereby DECLARE AND MANIFEST:

That for and in consideration of the amount of _____________

(P_____________) in cash, in hand received by me to my full and complete
satisfaction, and the payment and settlement by _____________ of the necessary
repairs and expenses incurred by my vehicle for damages sustained, 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, successors and assigns hereafter may have upon or by
reason of the damage sustained by our _____________ motor vehicle with Plate
No. ______________ arising from the accident which happened on
_____________ at _____________ involving our said _____________ registered
in the name of the undersigned _____________ and 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.



__________________ __________________


BEFORE ME, personally appeared , this in the City of

Mandaue, Philippines with his government issued identification card, as above indicated, and
known to me be the same person who executed the foregoing special power of attorney and
acknowledged to me that the same is his true and voluntary act and deed.

IN WITNESS WHEREOF, I hereunto set my signature and affix my notarial seal the day,
month and year first above-written.

Doc. No._____;
Page No._____;
Book No. _____;
Series of 2018.