RELEASE, WAIVER AND QUITCLAIM

KNOW ALL MEN BY THESE PRESENTS:

That I, ________________, Filipino, of legal age, married and a resident of ____________, do by

these presents acknowledge from _________________, as full payment and final settlement of all
my claims of whatever kind and nature which I have or may have against _____________, arising
from the vehicular accident which transpired on _______________ at _____________ to which
__________________ is not at fault and completely free of any liability as the said incident is
purely an accident and unintentional arising from circumstance that __________ has no control or
influence of whatsoever.

In consideration of said payment and prompt assistance, I do hereby quitclaim, release, discharge
and waive any and all actions of whatever nature, expected, real or apparent, which I may have
against ___________________ by reason of or arising from ______________. I will institute no
action whether civil, criminal or administrative against _______________. Any and all actions
which I have commenced either solely in my name or jointly with others before any office, board,
bureau, court or tribunal against ___________ are hereby deemed and considered voluntarily
withdrawn by me and I will no longer testify or continue to prosecute said action.

I declare that I have read this document and have fully understand its contents. I further declare
that I voluntarily and willingly executed this Release, Waiver and Quitclaim with full knowledge
of my rights under the law.

IN WITNESS WHEREOF, I have hereunto set our hands this _____________ at _____________,
Philippines.

AFFIANT

SIGNED IN THE PRESENCE OF:

__________________ __________________