INDIVIDUAL’S RELEASE OF ALL CLAIMS State of ________________________________________ County of ______________________________________
The undersigned, _________________________________________________ (name), of ___________________________________________________________ (address), here referred to as releasor, for and in consideration of __________________________ ________________________________________ (recite thing, act, promise or amount of money in return for which release is being given) (where consideration is money, add: the receipt of which is hereby acknowledged,) (where an action has been filed on the claim, and the defendant in the action has interposed a counterclaim that is being dismissed as part of the consideration for the release, add: and in further consideration of the execution by _________________________________________, releasee, of a dismissal with prejudice of releasee’s counterclaim against the undersigned in the case of _____________________________ v. ______________________________, Civil Case No. ______________, in the _________________ (specify court), releasor, being of lawful age, does hereby release, acquit and forever discharge releasor and all other persons and entities of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage resulting or to result from the accident that occurred on or about __________ (date), at or near ______________________________________ (describe location).
Releasor declares and represents that the injuries sustained are permanent and progressive and that recovery therefrom is uncertain and indefinite. Releasor further declares and represents that in making this release and agreement, it is understood and agreed that: (1) Releasor relies wholly upon releasor’s own judgment, belief and knowledge of the nature, extent and duration of such injuries; and (2) Releasor has not been influenced to any extent whatever in making this release by any representations or statements regarding such injuries, or regarding any other matters, made by the person(s), firm(s) or corporation(s) who are hereby released, or by any person or persons representing such person(s), firm(s) or corporation(s), or by any physician or surgeon employed or compensated by such person(s), firm(s) or corporation(s).
It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that the payment made hereunder is not to be construed as an admission of liability on the part of releasor, by whom liability is expressly denied.
It is the intention of the undersigned in signing this release to bind ________________ (himself or herself), (if applicable, add: _____________________________ (name of spouse), _____________ (his or her) spouse, and) ______________ (his or her) heirs, executors, administrators and assigns. This release is for the benefit of releasee and releasee’s agents, successors, heirs, executors, administrators, assigns, and all others who may be liable to releasor for damage to person or property arising out of the above-described accident.
(If required by statute, add: All rights given by _____________________ (cite statute), which states: __________________________________________________________ ____________________________________________________________________ _________________________________________________ (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), are waived by releasor.) This release contains the entire agreement between and among the parties hereto, and the terms of this release are contractual and not a mere recital.
I, the undersigned, have carefully read the foregoing release and know and understand the contents thereof. I sign this release voluntarily as my own free act with full knowledge of its significance, intending to be legally bound thereby.
Signed at ____________________ (designate place of execution).
_____________________________________ Signature
_______________________ Date
Executed in the presence of: ______________________________________________ ______________________________________________
______________________________________________
______________________________________________ (Signatures of witnesses, with names and addresses indicated for each person)
(Attach statement of attorney, if desired.)