HomeMy WebLinkAbout20160606 CountyofSLO Release 193353606/06/2016 15:38 8057811044 SLO COUNTY HR PAGE 01/01
La aworkv P11104-1116MAT1105 KI
.KNOW ALL MEN BY TFIFS'1:. PRI.'..SENTS:
'Mat the Undersigned, being of lawful age, for sole consideration of Nine Hundred Seventy-
Three
eventyThree and 29/100 Dollars ($1973.29) to be paid to County of San Luis Obispo do/sloes hereby and for my/our/ics heirs, executors, administrators,
successors and assigns release, acquit and forever discharge City of San .Luis Obispo, California and bis, 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 claims,
actions, causes of action, demands, rights, damages, costs, loss of service, expenses and compensation whatsoever, which the undersigned now
has/have or which may hereafter acerae on account of or in any way growing out of any and all known and unknown, foreseen and unforeseen
bodily and personal injuries and property damage and the consequences thereof resulting or to result from the accident, casualty or event which
occurred on or about the 30"' day of September, 2015,.at or near .1.1.19 Palm Street, San Luis Obispo, CA.
It is understood and agreed that this settlement is the compromise of a doubtful and disputed claim, anti that the payment made is not to be
Construed as an admission of liability on the part of the party or parties hereby released, and that said releases deny .liability therefor and intend
merely to avoid litigation and buy their peace.
It is further understood and agreed that allrights under Section 1542 of the Civil Code of California and any similar law of any state or territory of
the United States are hereby expressly waived. Said section reads as follows:
"1542. Certain claims not affected by general release. A general release does not extend to claims which the creditor does not
know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected
.his settlement with the debtor."
The undersigned hereby declate(s) and represent(s) that the injuries sustained are or may be permanent and progressive and that recovery
therefrom is uncertain and indefinite and it [Waking this Release it is understood and agreed, that the undersigned rely(ies) wholly upon the
undersigned's judgment, belief and knowledge of the nature, extent, effect, and duration of said injuries and liability therefor and is matte without.
reliance upon any statement or representation of the patty or parties hereby released or their representatives or by any physician or surgeon by
them employed.
The undersigned further deolare(s) and represent(s) that no promise, inducement or agreement not herein expressed has been made to the
undersigned., and that this Release contains the entire agreement between the parties hereto, and that the terms of this Release are contractual and
not a mere recital.
I hereby represent that at the time I sign this Release I am not hospitalized in a medical facility nor was I admitted to a medicalfacility withinthe
past 1.5 days.
TM UNDERSIGNED 11.4-9 READ T ft ABOTE.AND 1PULLY UNDERSTANDS 1'1 TO BE A FULL AND FINAT, PRLFASE OF ALL, CLAIMS.
Signed, sealed and delivered this 01 r4 day o,
Witness to aignainto
Address of Witness
Witness to sigaatuc
Signature
Address of Witness Signature
A N
For your protection California law requires the following to appear on this form.
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may, be subject to fines
and confinement in state prison.
ACKNOWLEDGMENT 11,N,UT:R OATH
State of
I SS
County of
Before me this
day of
came
known to me to be the individual who executed this release, and acknowledged that fully understood its
contents and freely executed same for the sole consideration therein expressed.
CW Pile: 19335M
RECEIVE; 2016-06-06 15:39:36 (GMT •08;00)
Notary Public
CW072