RELEASE, WAIVER AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

I, (PANGALAN), Filipino, of legal age, with address (complete address), state that:

1. On January 1, 2000, the subject (vehicle 1 model/make) with plate no. (vehicle 1 plate no.)
was hit by a (vehicle 2 model/make) driven by (driver 2 model/make) and owned by (company
name) with plate no. (vehicle 2 plate no.) along (complete address of place of accident). By
reason of such an accident, I as a passenger of the subject (vehicle 1 mode/make) incurred
injuries.

2. In settlement of the incident, I acknowledge receipt of the total amount of THIRTY-

TWO THOUSAND EIGHT HUNDRED EIGHTY-TWO PESOS AND 90/100 ONLY (PHP
32,882.90) from (company) to cover my loss of income and other expenses amounting to EIGHT
THOUSAND SEVEN HUNDRED NINETY-NINE PESOS AND 80/100 ONLY (PHP
8,799.80) and for hospital billing amounting to TWENTY-FOUR THOUSAND EIGHTY-
THREE PESOS AND 10/100 ONLY (PHP 24,083.10). This sum constitutes the fair settlement
of my claim, which I unconditionally and irrevocably accept.

3. I also acknowledge that the incident, although unfortunate, was brought about by
accident, with no one at fault, and there was no negligence on the part of either party.

4. In consideration of the foregoing sum, I fully and unconditionally waive or abandon any
claim I have against, and discharge (driver 2), his employer/s (company), and the latter’s
directors, shareholders, officers, employees, affiliates, and related companies from any claim
and/or liability arising from or connected with the aforementioned accident.

5. In addition, I will institute no action, whether civil, criminal, or administrative against

(driver 2), his employer/s (company), and the latter’s directors, shareholders, officers,
employees, affiliates, and related companies from any claim and/or liability arising from or
connected with the said vehicular accident.

6. I have read this document, and this Release, Waiver and Quitclaim executed herein is
given by me, willingly and voluntarily, having had the opportunity to seek guidance from
counsel.

7. This Release, Waiver and Quitclaim shall be valid and binding without need of any
further act, including notarization.

IN WITNESS WHEREOF, I have hereunto set my signature this __________ 2024 in

________________________________.

(NAME)
Affiant

SUBSCRIBED AND SWORN TO before me this _________, 2024. Affiant exhibited to me his
government-issued ID no. (id no.).

Doc. no. _____

Page no. _____
Book no. _____
Series of 2024.