AMICABLE SETTLEMENT WITH QUITCLAIM

This AMICABLE SETTLEMENT WITH QUITCLAIM (AGREEMENT) is entered on This Day by and
between:

ME, of legal age, Filipino, and a resident of Tarlac City, and YOU, of legal age, Filipino, and a
resident of Tarlac din, collectively hereinreferred to as the First Party;

And

They, of legal ages, married, and a resident of Tarlac, hereinafter referred to as the Second
Party;

WHEREAS, the First Party filed a case of Reckless Imprudence Resulting in Physical Injury and
Damage to Property with NPS Docket No. III-17-INV-16G-00525 (the case);

WHEREAS the Second Party has offered to shoulder the hospital expenses and provide financial
assistance to the First Party;

WHEREAS the FIRST PARTY has agreed to accept the offer of the Second Party;

WHEREAS in view of the mutual agreement between both parties, the FIRST Party has further
agreed to dismiss the case;

NOW, therefore, the parties agree as follows:

1. The Second Party agrees to deliver to the First Party the amount of P56,900 to KLIDJA
ACE CANLAS and the amount of PhP12,100 to FRANKLIN TACUSALME upon the
execution of this Agreement;

2. The FIRST PARTY hereby acknowledges the receipt of the aggregate amount of
PhP69,000 on _________________ at ______________ as full payment for all the civil
liabilities that the Second Party has incurred to the First Party by virtue of the vehicular
collision that took place on July 8, 2016 at Tariji, Tarlac City, Tarlac;

3. By virtue of the payment made by the Second Party, the First Party hereby quitclaim,
release, discharge and waive any and all actions of whatever nature, expected, real or
apparent, which they may have against the Second Party;

4. Further, the First Party, in view of this Agreement, agrees to cause the termination of
the case by personally filing with the office of the city prosecutor an Affidavit of
Desistance on September 27, 2016;

5. The First Party, in view of having received full compensation for the injuries and material
damage they incurred, agrees to turn over to the Second Party whatever insurance
proceeds they may receive from the insurer of the Second Party;
ACKNOWLEDGMENT
Republic of the Philippines)

Tarlac City ) s.s.

I certify that on _________________, before me, a Notary Public duly authorized in Tarlac City
to take acknowledgment, personally appeared:

Name Competent Evidence Date/Place of Issue

of Identity and ID No.

who are identified by me through competent evidence of identity to be the same persons
described in the foregoing instrument, who acknowledged before me that their respective
signatures on the instrument were voluntarily affixed by them for the purposes stated therein, and
who declared to me that they have executed the instrument as their free and voluntary act and
deed and that they have the authority to sign on behalf of their respective principals.

WITNESS my hand and seal on the date and place stated above.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2016.