RELEASE WAIVER AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

That I, _____________, Filipinos, of legal ages, residents of Ilagan City, Isabela,
after being sworn to in accordance with law, do by these presents:
1.

I acknowledge full and final settlement in the amount of

__________(P_______)for the payment of hospital and medical bills and
expenses and the damage sustained by my Euro single motorcycle, in
connection with the vehicular accident that occurred on October 25, 2015;

2. That for the consideration above mentioned for myself, my heirs, representatives,
successors and assigns I do hereby forever release, discharge and absolve
______________, of and from all actions, claims and demands whatsoever that
now exist or may hereafter develop and particularly on account of all known,
unknown and unanticipated injuries and damages arising out of and in
consequence of the accident occurring on October 25, 2015 at about 6:00 in the
evening along national hi-way at Brgy. San Isidro, Ilagan City, Isabela, when we
sustained serious physical injuries when NELSON AGCAOILI and JOMER
AGCAOILI accidentally bumped my Euro single motorcycle;
3. That the consideration above mentioned is voluntarily accepted as full and final
compromise, adjustment and settlement of all claims with respect to both civil
and/or criminal actions that may have been filed in connection with the above
accident;
4. That the payment of said amount shall never be construed as an admission of
liability by ______________;
5. That I will not institute any criminal and/or civil actions against ______________;
6. That any and all actions which I may have commenced either solely in my name
or jointly with others before any office, board, bureau, court, or tribunal against
______________ are hereby deemed and considered voluntary withdrawn by me
and I will no longer testify or continue to prosecute said action(s);
7. That I declare that I have read this document and have fully understood its
contents. I further declare that I voluntarily and willingly executed this Release,

Waiver and Quitclaim with full knowledge of my rights under the law. That the
contents of this document, although prepared in English, was interpreted and
explained to me in Pilipino by the undersigned counsel and the same is therefore
understood by me.

IN WITNESS WHEREOF, I have hereunto set my hand at ____________,

Isabela this _____ day of __________ 2013.

Affiant

SIGNED IN THE PRESENCE OF:

_______________________

______________________

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF ISABELA
)S.S
Municipality of ___________ )
BEFORE ME, a Notary Public for and in the Province of Isabela, personally
appeared:

Name

Valid ID

Date/Place Issued

Known to me and to me known to be the same persons who executed the

foregoing instrument and acknowledged to me that the same are their free
act and voluntary deed.

This instrument, consisting of TWO pages, including the page on which this
acknowledgment is written, has been signed on the left margin of each and
every page thereof by the concerned parties and their witnesses, and sealed
with my notarial seal.

WITNESS MY HAND AND SEAL on this __ th day of __________ 2013 at

_____________, Isabela.

Doc. No. ______;

Page No. ______;
Book No. _____;
Series of 2016.