RELEASE OF CLAIM

FOR THE SOLE CONSIDERATION OF PESOS Twelve thousand pesos_ (Amount in Words)

(Php 12,000.00), the receipt thereof is hereby acknowledged:

I/We ____________________________ (Claimant Name) for myself/ourselves, my/our heirs,

representatives, successors and assign do hereby release and forever discharge Sharon Chan and
Rolando Mendoza and associates of and from all actions, claims and demands whatsoever that now
exist or may hereafter develop with respect to the vehicle damage and/or injury to person and/or
damage to property from accident which happened last February 22, 2024(Date) along Soler St. Manila
(street, Brgy., City) between vehicles with Plate No. ______________and Plate No.__________________.

I/We hereby declare that the foregoing sum is voluntarily accepted as a full and final compromise,
adjustment and settlement of all claims, that the payment of said amount shall not be construed as an
admission of liability by the parties hereby released, and that I have read and fully understood this
instrument before signing the same, That I have signed this instrument willingly and voluntarily and with
full knowledge of its legal effects, and that I have executed this instrument with the assistance and
advice of counsel.

IN WITNESS WHEREOF, I/We have set my/our hands this ______________________

__________________________
Claimant Name

SIGNED IN THE PRESENCE OF:

_________________________ _________________________
 REPUBLIC OF THE PHILIPPINES

PROVINCE OF _________)S.S..

CITY/MUNICIPALITY OF )

Before me, Notary Public, for and in the ______________________________ City, Philippines, this
_________ day of _____________________ personally appeared with ID No.
______________________issued on ________________at ______________________, known to me and
to me known to be the same person who executed the foregoing instrument, and acknowledged to me
that the same is his/her free and voluntary act and deed.

Doc. No.;

Page No.;

Book No. __________;

Series of _______.