The undersigned, being of lawful age, for sole consideration of one thousand seven hundred seventy nine 50/100  dollars

($1,779.50 ) to be paid to Jane Doe do/does hereby and for my/our/its heirs, executors, administrators, successors and assigns release, acquit and forever discharge John Doe and his, her, their, or its agents, servants, successors, heirs, executors, administrators, and all other persons, firms, corporations, associations or partnerships of and from any and all property damage claims, actions, causes of actions, demands, rights, damages, costs, loss of service, expenses, and compensation whatsoever, which the undersigned now has/have or which may hereafter accrue on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen property damage and the consequences thereof resulting or to result from the accident, casualty or event which occurred on or about 01-01-2013 at or near 123 Main Street, Atlanta GA.


AUTHORITY:  I/we have full authority to execute a binding release of the above-referenced claim.  I/we have not assigned this claim to anyone else.  There is no guardian, trustee, executor, administrator, or other person or entity with power to approve or disapprove settlement of the above referenced claim.


NOTICE AND ACKNOWLEDGMENT:  I/we understand and agree that the consideration stated is paid by the liability insurance carrier for a party released hereby.  I/we have been informed, prior to executing this instrument, that the payment is made by the insurance carrier as an independent contractor without consent to settle on behalf of any person released hereby, and that payment to the Undersigned shall have no effect upon, nor preclude any claim or claims, if any, by any party released against the Undersigned or those through whom the Undersigned makes claim. I/we hereby acknowledge the foregoing notice, furnished in accordance with Georgia law, and also receipt of a copy of this instrument.




Signed, sealed and delivered this ________ day of _______________________________, 20______.


Witness Signature _________________________________ Your Signature ___________________________________


Witness Signature _________________________________ Your Signature ___________________________________


State of ________________________, County of ______________________.


On this ______ day of ____________, 20____.  Before me personally appeared ________________________________, to me known to be the person described herein, and who executed the foregoing instrument and he/she acknowledged that he/she voluntarily executed the same.


My term expires _____________________, 20______   ____________________________________________________

Notary Public


CLAIM NUMBER:  123456789