Republic of the Philippines)

) s.s.

AFFIDAVIT OF QUITCLAIM AND RELEASE

I, (VICTIM’S NAME), of legal age, Filipino and a with address at

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

1. That I am the victim in an accident that transpired on (DATE OF ACCIDENT),

at (PROXIMATE LOCATION OF THE ACCIDENT), was accidentally hit and
bumped by a certain (CAR MODEL) with plate no. _____________, being
driven by (NAME OF YOUR FATHER).

2. That by reason of said unexpected incident, I was given medical care and
assistance at (Hospital Name).

3. That (YOUR NAME) assisted and shouldered all the expenses incurred for
my treatment, operation, and medications in the amount of
Php________________, representing all the costs for treatment and recovery
in its entirety ;

4. That due to the foregoing, I hereby discharge and forever release (NAME OF
YOUR FATHER ) of any and all whatever claims, whether civilly (monetary or
otherwise), criminally or administratively.

5. That I hereby further state that I have no more claims, whether past, present
or future against (YOUR NAME) and (FATHER’S NAME);

6. That I have voluntarily executed this statement, after the contents thereof
were explained a language understood by me and in the presence of
witnesses, to attest to the truth of the above and for all legal intents and
purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________________________________________________________

Affiant

Witness:

SUBSCRIBED AND SWORN to before me this ________________________ in

______________________________________________________________________.

Doc. No. ___;

Page No. ___; Notary Public
Book No. ___;
Series of _____
Republic of the Philippines)
) s.s.

AFFIDAVIT OF QUITCLAIM AND RELEASE

I, (VICTIM’S NAME), of legal age, Filipino and a with address at

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

1. That I am the victim in an accident that transpired on (DATE OF ACCIDENT),

at (PROXIMATE LOCATION OF THE ACCIDENT), was accidentally hit and
bumped by a certain (CAR MODEL) with plate no. _____________, being
driven by (NAME OF YOUR FATHER).

2. That by reason of said unexpected incident, I was given medical care and
assistance at (Hospital Name).

3. That (YOUR NAME) assisted and shouldered all the expenses incurred for
my treatment, operation, and medications in the amount of
Php________________, representing all the costs for treatment and recovery
in its entirety ;

4. That due to the foregoing, I hereby discharge and forever release (NAME OF
YOUR FATHER ) of any and all whatever claims, whether civilly (monetary or
otherwise), criminally or administratively.

5. That I hereby further state that I have no more claims, whether past, present
or future against (YOUR NAME) and (FATHER’S NAME);

6. That I have voluntarily executed this statement, after the contents thereof
were explained a language understood by me and in the presence of
witnesses, to attest to the truth of the above and for all legal intents and
purposes.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________________________________________________________

Affiant

Witness:

SUBSCRIBED AND SWORN to before me this ________________________ in

______________________________________________________________________.

Doc. No. ___;

Page No. ___; Notary Public
Book No. ___;
Series of _____