OF PENDING ACTION
___________________________________________________________ (name), of
_________________________________________________________ (address), the undersigned, with the intent of binding
myself, (if applicable, here add:
_________ ____________________________ (name of spouse), my spouse,) and
my heirs, legal representatives and assigns, execute this release in favor of
______________________ (name), of
___________________________________________________ (address), here referred to
consideration of the sum of ____________ Dollars ($__________ ), receipt of
which from releasee is acknowledged, I release and discharge releasee and __________
(his or her) heirs, legal representatives and assigns, from all claims, present
and future, known or unknown, in any manner arising out of property damage and
personal injuries sustained by me as a result of
(description of incident forming basis of claim).
appropriate, insert here: I
specifically waive any rights I may have under ________
(cite applicable statute) as to unknown or unsuspected claims, which provides
as follows: _____________________________________________________
(quote statute verbatim; for example: A
general release does not extend to claims that the releasor does not know or
suspect to exist in the releasor’s favor at the time of executing the release,
which if known by the releasor must have materially affected the releasor’s
settlement with the releasee or otherwise as the case may be).
authorize releasee to pay the consideration for this release directly to my
attorney, _____________________________________ (name), Attorney at Law, whose
office is located at _____________________________________________________
authorize and direct my attorney, ___________________________________ (name),
to execute __________ (in duplicate) a _____________________________ (motion
for dismissal with prejudice) of the _____________ (complaint or petition or
declaration) in the action now pending in the _______________________________
(specify court), entitled ______________________________ v
_______________________________, Civil Case No.
_________________________________________, involving the claim described above
in this release. A copy of such __________________ (motion) will be delivered
to ______________________________________ (name), Attorney at Law, whose office
is located at _________________________________________________ (address),
attorney for releasee, contemporaneously with the payment of ____________
Dollars ($__________) as previously set out by the terms of this release.
have read this release and understand all its terms. I execute it voluntarily
and with full knowledge of its significance.
witness whereof, I have executed this release at ____________________
(designate place of execution) on __________ (date).
statement of attorney, if desired.)