RELEASE OF CLAIM

I, XXXXX, Filipino, of legal age, with at office address at Pasig

City, hereby declare and manifest:

That I have received from ________________, to my full

and complete satisfaction, the amount of
_____________________ as payment/settlement for the repairs
of the damage sustained by my TOYOTA VIOS motor vehicle with
Plate No. ABC-123 arising from the vehicular accident which
happened on _____________________ at
________________________ involving my said motor vehicle
and another motor vehicle being driven by the said
__________________.

That I hereby absolutely release, and forever discharge the said

_______________ from any cause of action, sum of money,
liability, damages, claims and demands whatsoever, which in law or
in equity, I, my heirs, insurer, successors and assigns hereafter may
have in connection with the aforementioned vehicular accident.

I also manifest that the said payment/settlement made shall not

be taken by me, my heirs, insurer or assigns, as a confession and/or
admission of liability on the part of the said _____________ in
relation to the said accident.

IN WITNESS WHEREOF, I have hereunto set my hand this

_____________ at _____________, Philippines.

XXXXX

SIGNED IN THE PRESENCE OF:

_________________ __________________
REPUBLIC OF THE PHILIPPINES)
________________________) S.S.

ACKNOWLEDGMENT

BEFORE ME, personally appeared:

Name Identification Date issued

Known to me to be the same person who executed the foregoing

instrument and acknowledged to me that the same is his free and
voluntary act and deed.

WITNESS MY HAND AND SEAL, on the date and place first above
written.

NOTARY PUBLIC

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2019.