RELEASE AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

THAT I, ______________________________________, of legal age and

with residence address at _________________________________________
_____________________, being sworn to in accordance with law hereby depose
and state:

For and in consideration of the full payment of all my claims relating to the
damages in a vehicular accident caused on my car, described as (model, type, year,
color, and plate number), by the vehicle driven by Mr. _______ last (date and
time), and in full settlement of all my claims amounting to PhP_________, and
receipt of the same is hereby acknowledged from Mr. _________, of legal age, and
resident at (address), I hereby completely and absolutely discharge and release Mr.
_____, his representatives, agents, successors and assigns from all any liabilities
arising wholly or partially, directly or indirectly from the aforementioned vehicular
accident.

I have read this document and understood the same. The release, quitclaim,
and undertaking herein is given by me willingly and voluntarily and that this
document covers a complete settlement of all my claims against Mr. ________, his
representatives, agents, successors and assigns.

Signed this _________________________(date) in the City of Parañaque.

_____________________________
AFFIANT
Signed in the presence of:

______________________________ ______________________________

SUBSCRIBED AND SWORN before me this _____ day of __________,

2021, affiant exhibited to me his _____________________ issued at
__________________ on _________________.

Notary Public

Doc No. _____________;

Page No._____________;
Book No. ____________ ;
Series of 2021.