RELEASE WAIVER QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

That I, _________________________, Filipino, of legal age, married and a

resident of Purok-2, Brgy. Tinambacan Norte, Calbayog City, do by these presents
acknowledge and express my deepest gratitude to Xunrong Zou of Brgy. Solsogon, Sta.
Margarita, Samar, for answering the medical expenses, surgery and hospital
confinement amounting to
_______________________________________________________________
(___________) more or less plus receipt of the sum of
___________________________ (___________) Philippine Currency, in full payment
and final settlement of all my claims of whatever kind and nature which I have or may
have against Xunrong Zou, arising from my injuries as a result of the vehicular accident
which transpired on September 16, 2019 at Brgy. Tinambacan, Calbayog City, Samar,
to which Xunrong Zou is not at fault and completely free of any liability as the said
incident is purely an accident and unintentional resulting from circumstances that
Xunrong Zou 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 Xunrong Zou by
reason of or arising from my injuries. I will institute no action, whether civil, criminal, or
administrative against Xunrong Zou. 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tribunal against Xunrong Zou are hereby deemed and considered voluntary withdrawn
by me and I will no longer testify or continue to prosecute said actions.

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

IN WITNESS WHEREOF, I have here unto affixed my signature this ____ day of
_______ 2019.

________________________
Affiant