RELEASE, WAIVER AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

I, (name), Filipino, of legal age, single and a resident of Brgy. ____, do by these presents
acknowledge and express my deepest gratitude to (name of driver) of Brgy. ____ for answering
my medical expenses and hospital confinement amounting to (payment), in full payment and
final settlement of all my claims of whatever kind and nature which I have or may have against
(name of driver), arising from my injuries as a result of a vehicular accident which transpired on
(date of incident) at (place of incident), to which (name of driver) is not at fault and completely
free of any liability as the said incident arose from circumstances that (name of driver) has no
control or influence whatsoever.

In consideration of said payment and generous medical and hospitalization assistance, I

do hereby quitclaim, release, discharge and waive any and all actions of whatever nature,
expected, real or apparent, which I may have against (name of driver) by reason of or arising from
my injuries. I will institute no action, whether civil, criminal or administrative, against (name of
driver). Any and all actions which I may have commenced either solely in my name or jointly with
others before any office, board, bureau, court or tribunal against (name of driver) are hereby
deemed and considered voluntarily withdrawn by me and I will no longer testify or continue to
prosecute said action/s.

I declare that I have read this document and have fully understood its contents. I further
declare that I voluntarily and willingly executed this Release, Waiver and Quitclaim with full
knowledge of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ in June __, 2018.

__________

Witnesses:

________ ________

SUBSCRIBED AND SWORN TO before me this ___ of June 2018 in ____, affiant exhibiting
to me his valid ID No. _______.