RELEASE

FOR THE SOLE CONSIDERATION OF  __________________ Dollars,
and other consideration, the receipt and sufficiency whereof
is hereby acknowledged, the undersigned hereby releases and
forever discharges ___________________________, their heirs,
executors, administrators, agents and assigns, and all other
persons, firms or corporations liable or who might be
claimed to be liable, none of whom admit any liability to
the undersigned but all expressly deny any liability, from
any and all claims, demands, damages, actions, causes of
action or suits of any kind or nature whatsoever, and
particularly on account of all injuries, known and unknown,
both to person and property, which have resulted or may in
the future develop from an accident which occurred on or
about the    day of        ,19  , at or near ______________
__________________________________________________________.

The undersigned hereby declares that the terms of this
settlement have been completely read and are fully
understood and voluntarily accepted for the purpose of
making a full and final compromise adjustment and settlement
of any and all claims, disputed or otherwise, on account of the
injuries and damages above mentioned, and for the express
purpose of precluding forever and further additional claims
arising out of the aforesaid accident.

The undersigned hereby accepts draft or drafts as final
payment of the consideration set forth above.

IN WITNESS WHEREOF, we have hereunto set our hands and seals
this ___ day of __________, 19__.

Signed, sealed and delivered
in the presence of:

___________________________    _______________________(SEAL)
___________________________    _______________________(SEAL)