READ CAREFULLYBY SIGNING THIS INSTRUMENT YOU GIVE
UP EVERY RIGHT YOU HAVE.
I, ________ (name), Age ___________, _______ (married or single), residing at ____________ (address), in exchange for _____ Dollars ($_____) which I have received, do hereby ____________ (Write the word release to show that you know what you are doing) and forever discharge _________ (name) and their heirs, executors, administrators, successors and assigns, and their several vessels and in particular the SS. ________ and the owners, agents, operators, charterers, masters, officers and crews of such vessels, from each and every right and claim that I now have, or may hereafter have on account of injuries and illnesses suffered by me as follows: _________, and, in addition to that, I ____________ (Write the word release to show that you know what you are doing) them from each and every right and claim that I now have or may hereafter have because of any matter or thing that happened before the signing of this paper, it being my intention by the signing of this paper to wipe the slate clean as between myself and the parties released, even as respects injuries, illnesses, rights and claims not mentioned herein or not known to me.
(1) I know that this paper is much more than a receipt. It is a release. I am giving up every right I have.
(2) I know that in signing this release I am, among other things, now settling in full for all injuries, illnesses and disabilities that I have had already, that I have now, and that I may have in the future, either because of the particular occurrence mentioned above or because of any other occurrence in the past, or because of both, even though I do not know that I have had already, have now or may have in the future such injuries, illnesses and disabilities, and even though they are not mentioned particularly in this release; and I do all this regardless of what anyone may have told me about my injuries, illnesses and disabilities or about anything else.
(3) I know that doctors and other persons make mistakes, and I am taking the risk that what they may have told me is wrong. If that should be the case, it is my loss, and I cannot back out of the settlement.
(4) I realize that the payment of the money mentioned above is not an admission that anyone is liable to me for anything.
(5) I am signing this release because I am getting the money. I have not been promised anything else.
(6) I am satisfied.
THE FOLLOWING IS TO BE FILLED IN BY THE CLAIMANT
PERSONALLY IN THE CLAIMANTS OWN HANDWRITING.
A. Have you read this paper from beginning to end? _______________
B. Do you know what this paper is that you are signing? ____________
C. What is this paper which you are signing? _____(Write here release of everything)
D. Do you make the six numbered statements printed above and do you intend that the parties whom you are releasing shall rely on the statements as the truth? _________
E. Do you know that signing this paper settles and ends every right or claim you have for damages as well as for past and future maintenance, cure and wages? ________
F. In order to show that you know what you are doing, please copy in your own handwriting, in the space immediately following, the third numbered statement above:
Therefore, I am signing my name on the words This is a Release and alongside the seal, which is printed below and which is adopted by me as my own, to show that I mean everything that is said on this paper.
Sign Here: __________________
This is a Release (Seal)
(Claimant, if he or she wishes to sign and seal this paper, should write his or her name on the words This is a Release immediately above and alongside the printed seal. )
(PLACE THE FOLLOWING ON THE REVERSE SIDE OF THIS FORM)
Certificate of Witnesses
We, the undersigned, do hereby certify that the release that is set forth on the reverse side of this paper was executed in our presence and that the claimant acknowledged that he or she fully understood the contents of the document and that it was a release of everything and that he or she executed the same as his or her free act and deed and in exchange for __________ Dollars and __________ Cents, as therein set forth, and for that only.
Witness our hands and seals on ______________ (date).
(Signature) _____________________ (Seal)
(Signature) ______________________ (Seal)
(Signature) ____________________ (Seal)