FOR THE SOLE CONSIDERATION OF __________________ Dollars,
and other
consideration, the receipt and sufficiency whereof
is hereby
acknowledged, the undersigned hereby releases and
forever discharges
___________________________, their heirs,
executors, administrators,
agents and assigns, and all other
persons, firms or corporations liable
or who might be
claimed to be liable, none of whom admit any liability
to
the undersigned but all expressly deny any liability, from
any
and all claims, demands, damages, actions, causes of
action or suits of
any kind or nature whatsoever, and
particularly on account of all
injuries, known and unknown,
both to person and property, which have
resulted or may in
the future develop from an accident which occurred on
or
about the day of ,19 , at or near
______________
__________________________________________________________.
The
undersigned hereby declares that the terms of this
settlement have been
completely read and are fully
understood and voluntarily accepted for the
purpose of
making a full and final compromise adjustment and
settlement
of any and all claims, disputed or otherwise, on account of
the
injuries and damages above mentioned, and for the
express
purpose of precluding forever and further additional
claims
arising out of the aforesaid accident.
The
undersigned hereby accepts draft or drafts as final
payment of the
consideration set forth above.
IN WITNESS WHEREOF, we have
hereunto set our hands and seals
this ___ day of __________,
20__.
Signed, sealed and delivered
in the presence
of:
___________________________
_______________________(SEAL)
___________________________
_______________________(SEAL)