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Back to Forms for 'Releases and Settlements'.





I, ___________________________________________________________ (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 as releasee.


In 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). 

(If 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).


I authorize releasee to pay the consideration for this release directly to my attorney, _____________________________________ (name), Attorney at Law, whose office is located at _____________________________________________________ (address).


I 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.


I have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.


In witness whereof, I have executed this release at ____________________ (designate place of execution) on __________ (date).



_____________________________________                   _______________________

Signature                                                                               Date




(Attach statement of attorney, if desired.)



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