RELEASE WAIVER AND QUITCLAIM

with ACKNOWLEDGMENT RECEIPT

 
KNOW ALL MEN BY THESE PRESENTS:
           I, (NAME OF VICTIM OF VEHICULAR ACCIDENT), of legal age, Filipino,
single/married, and a resident of (Address of Victim), hereby DECLARE AND
MANIFEST – That:
1.     A vehicular accident happened on (Date of Accident) at (Place of Accident),
involving my (Description of First Vehicle) with Plate No.
______________, registered in the name of (Name of Vehicle Registered
Owner) and the (Description of Second
Vehicle) with ______________, owned by the (NAME OF REGISTERED
OWNER OF SECOND VEHICLE);
 
2.     For and in consideration of the amount of (AMOUNT IN WORDS)
(PhP______________) in cash, in hand RECEIVED BY ME to my full and
complete satisfaction, as payment and settlement by (NAME OF DRIVER
OF SECOND VEHICLE) of the hospital and medical bills, as well as
expenses incurred by the undersigned for injuries sustained, I hereby
absolutely RELEASE, COMPLETELY CLEAR, and FOREVER
DISCHARGE the said (NAME OF DRIVER OF SECOND VEHICLE) 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
injuries sustained by me, and the damage sustained by (Description of First
Vehicle), arising from the said incident;
 
3.     I hereby intentionally, completely and absolutely WAIVE all my right of
action, causes of action, claims and demands, of whatever nature, arising
from, or in connection with the aforementioned incident;
 
4.     I further warrant that I will institute no further action against the said (NAME
OF DRIVER OF SECOND VEHICLE) arising from, by reason of, or in
connection with, the aforementioned incident;
 
5.     I likewise manifest that the said payment / settlement made by the said
(NAME OF DRIVER OF SECOND VEHICLE) 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 (NAME OF DRIVER OF SECOND VEHICLE) in
connection with the aforementioned incident;
 
6.     Further, I completely and absolutely exonerate (NAME OF DRIVER OF
SECOND VEHICLE) from any liability in connection with the above-
mentioned incident;
 
7.     This release extends to claims arising out of this incident that are not known
by me at the time this release is signed; and
 
8.     I have read this document and have fully understood its contents. I voluntarily
and willingly execute this Receipt and Release with full knowledge of my
rights under the law.
            IN WITNESS WHEREOF, I have hereunto set my hand at (Date of Signing) at
(Place of Signing), Philippines.
  
(NAME OF VICTIM OF VEHICULAR
ACCIDENT)
Releaser
 
WITNESSED BY:      _______________________              ______________________
 
ACKNOWLEDGEMENT
Republic of the Philippines    )
City of _______________      ) S.S.
 
BEFORE ME A NOTARY PUBLIC, for and in the City of _____________, on
(Date of Signing), personally appeared (Name of Signatory) who presented his/her (ID
Details), valid until (Expiry Date), a government-issued identification document that
bears his/her signature and photograph, and being informed by me of the contents of the
foregoing instrument, he/she acknowledged before me that he/she executed the same on
his/her own free will and deed.
 
WITNESS MY HAND AND SEAL on the date and place first above written.
 
Doc. No. _____;
Page No. _____;
Book No. _____;
Series of _____.