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considered voluntary withdrawn by me and I will no longer testify or continue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