Republic of the Philippines

Province of Zamboanga del Norte S.S.

City of Dipolog
S
X--------------------X .
S
RELEASE, WAIVER AND QUITCLAIM
.

I, ___________________., Filipino, of legal age, married, and a resident of

__________________________________________________________, after being sworn to in
accordance with law, depose and state:

1. That by these presents, I hereby state that I am the

__________________________________________________

2. That on or about __________________ around __________ while roaming around

the ___________ City Boulevard, my son _____________ was accidentally hit by a vehicle
(Honda City Color: Black Plate Number _________________);

3. That my son ____________________________________, sustained injuries on

different parts of his body;

4. That the driver of the vehicle was _________________________, _______ years

old, married and a resident of ___________________________ and a holder of Professional
Driver’s License _____________________________;

5. That __________________ personally brought my son,

_______________________________ to _________________________________for immediate
and appropriate medication;

6. That I hereby voluntarily and freely express my desire to settle for the injury of
my son, _____________________ peacefully and amicably to our mutual and common
advantage;

7. That this is no way is a manifestation or acknowledgement of liability or

negligence on the part of ______________________________ but rather is a manifestation of
goodwill, assistance and good faith in our favor;

8. That ______________________________ has offered by way of financial

assistance the payment of the total amount of hospital bills and medicines of my son;

9. That I hereby declare no further monetary claims whatsoever against

________________________________________ and that I hereby release and forever
discharge him from any and all monetary claims, demands, cause of action of whatever nature
arising out of this incident;

10. That I agrees that this QUITCLAIM may be pleaded in bar to any suit or proceeding
to which _________________________ may have against in connection with the injuries of my
son, __________________ and the financial assistance which I received as provided herein
should not in any way be construed as an admission of liability or negligence on the part of
__________________________
IN WITNESS WHEREOF, I have hereunto set my hand this __________ at
__________________________ City, Philippines.

______________
Affiant

SUBSCRIBED AND SWORN to before me, this __________, by ____________________ who

exhibited to me his ____________________ with No. ____________________ issued at
____________________, Philippines on __________.

NOTARY PUBLIC
Doc.No. _____;
Page No. _____;
Book No. _____;
Series of 2018