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这里有一份
自己酌情改改就可以了。# ~& A ?7 D% R# o( t% ?: k, O
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Settlement Disclosure
9 s6 E3 \2 j' ~7 YFinal Settlement
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CAR A:( q4 R' B$ g. J) ^3 O( z5 ~% X
Year -
8 b4 B5 Q6 K- c6 E/ K' U ^7 r9 lMaker/Model -
( u: Y) C d+ S( m& i3 i$ rSerial (VIN) # -/ j S3 l8 I1 i2 M# T; B/ X
Plate Number:
" |' s C/ D9 a2 U3 fDriver Name: (called driver A in this document)
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CAR B:
& X3 N& I- Q3 d" L I2 IYear -
# b9 Y3 q1 U# y3 OMaker/Model –
) j/ C) {# v; B, F# wSerial (VIN) # -
7 y1 L2 j. j1 O# k& F/ ?) yPlate Number:
}% I2 i9 ~5 A& F) q0 y r3 RDriver Name: (called driver B in this document)$ X9 A5 Y! O5 n9 p: o% P# P5 ]
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In the afternoon of Nov. 7th, 2007, car B hit the back of car A.
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) |8 M5 Y0 T. o sThe driver B has paid f/ f# R) v) \1 J- ]0 o. G. f
1. Bumper repair: $
) D+ N9 v, k: I9 V$ V& b% r2. Other Compensation: $/ U9 @0 c4 n0 ~, a% k/ J* G- e2 J* \ m
' k2 \- I- {3 {: l; p: {# e) |driver A and driver B agree to make a final and permanent settlement of this accident. Driver A has received the above amount of money. And Driver A agrees with this final settlement and is forever giving up the right to claim any responsibility of driver B or to proceed to judicial review by a court, concerning any result of this accident for damage of car A or injury of anyone in it.
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Driver A:
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4 j- V8 @: ? T6 J0 V! C9 PSignature Date:% b* ^, x7 u2 H; |& t4 [+ n* w \# Y; s7 \
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Driver B:! S! r. k: ]" _, Z& W/ d% ?
& ~9 D. }* p+ v0 q5 i% s, jSignature Date:
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# F; T! j4 \, S5 W6 q; fWitness:
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7 e( S+ G# D2 |* ^( xSignature Date: |
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