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 _____.
