WAIVER, RELEASE AND QUITCLAIM

I, _____________, Filipino, of legal age, single / married / widow, and a resident of

_____________, Philippines, after being sworn to in accordance with law, hereby depose and
state that for and in consideration of the amount of Five Thousand Pesos (PhP5,000.00) in cash,
in hand received by me to my full and complete satisfaction, I hereby absolutely release, relieve
and forever discharge _________________ from any action, cause of action, liability, damages,
claims and demands whatsoever, which I have in law or equity, or which my heirs, insurer,
successors and assigns hereafter may have upon or by reason of the injuries sustained by me, and
the damage sustained by my Bugatti Veyron with Plate No. ______________ arising from the
accident which happened on _____________ at _____________ involving the Pagani Huayra
with Plate No. _____________ driven by _______________ and registered in the name of
_________________ .
IN WITNESS WHEREOF, we have hereunto set our hands this ____ day of April 2016 at
____________________________________.
_____________________________
Affiant
Signed in the presence of:
___________________________________

___________________________________

SUBSCRIBED AND SWORN to on the date and at the place first above-written, the
affiant exhibiting to me his LTO License with No. ______________________ issued on
_____________________.

Doc. No. _____;

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