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- " For good and valuable consideration, \b and the
- "heirs, successors, and assigns of the undersigned hereby releases
- "forever discharges \a, his/her heirs, successors, and assigns from any
- "and all claims, debts, demands, liabilities, and causes of action
- "arising from: \c
- "
- " This release applies only to the foregoing obligation, and no
- "other liability by and between the parties, any of which, if existing,
- "shall survive this release. Signed on this \d day of \e, \f.
- "
- "
- " \z DATE: \z
- " (\b)
- "
- "
- "
- "STATE/COMMONWEALTH OF \z COUNTY/BOROUGH/PARISH OF \z
- "
- "BEFORE ME, the undersigned authority, on this day personally appeared
- "\a, known to me to be the person(s) whose name(s) is(are) subscribed
- "to the foregoing instrument, and acknowledged to me that he(she)(they)
- "executed said instrument for the purposes and consideration therein
- "expressed.
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- "GIVEN under my hand and seal of office on this \j day of \k, \l
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- "\m
- "Notary Public's Signature
- "(seal/stamp)
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