RELEASE, WAIVER AND QUITCLAIM

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

_____________________________________, after having been duly sworn to in accordance
with law, hereby depose and state that:

1. For and in consideration of the amount of _____________ (P_____________) in

cash, in hand received by me to my full and complete satisfaction, and the
payment and settlement by _____________ of the hospital and medical bills and
expenses incurred by the _____________ for injuries sustained, I hereby
absolutely release, completely clear, and forever discharge the said
_____________ and his driver _____________ 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 our _____________ motor vehicle with Plate No. ______________
arising from the accident which happened on _____________ at _____________
involving our said _____________ registered in the name of the undersigned
_____________ and the _____________ motor vehicle with Plate No.
_____________ owned by the said _____________ with the intention to
completely and absolutely waive all our right of action, causes of action, claims
and demands, of whatever nature, arising from, or in connection with the
aforementioned accident.

2. I further warrant that I will institute no further action against the said
_____________ and/or his driver _____________ arising from, by reason of, or in
connection with, the aforementioned vehicular accident.

3. I also manifest that the said payment/settlement made by the said _____________
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 _____________ or by his driver
_____________ in connection with the aforementioned accident.

IN WITNESS WHEREOF, I hereby affix my signature this _______________ in

_______________.

______________________________
Name and Signature

Signed in the presence of:

__________________ __________________
Republic of the Philippines )
________________________ ) SS.

ACKNOWLEDGMENT

BEFORE ME, a Notary Public for and in _______________, this _______________,

personally appeared _______________, exhibiting to me the following competent evidence
of identity: ______________________________, known to me and to me known to be the
same person who executed the foregoing instrument, acknowledging before me that the
same is his/her free and voluntary act and deed.

WITNESS MY HAND AND SEAL on the date and at the place written above.

Doc. No. ___;

Page No. ___;
Book No. ___;
Series of 2018.