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这里有一份
自己酌情改改就可以了。
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Settlement Disclosure
5 M) S8 X% G$ z: ZFinal Settlement- F- V9 ?& Q9 U& @5 u
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CAR A:
; Q' G0 x ~2 J7 C! FYear -
" t5 M; K" I: Q! k9 T* z7 d* FMaker/Model -$ w" b6 z5 k. l/ v
Serial (VIN) # -
) @8 s) p& b* T& k: W0 SPlate Number:
3 z% z, {- D& d/ [; G7 c* oDriver Name: (called driver A in this document)% d! k" N. H% r5 K8 z( R# W
9 }* Z7 ?7 K! h6 C/ nCAR B:- o1 w. R$ u) C, ^' Z; c. @
Year -
: E1 R8 E6 ?; t# _1 `Maker/Model –& [4 V8 o+ r D% h: P+ ?
Serial (VIN) # -
/ z( z. n; p D- U7 HPlate Number:7 Y' A! p, Y$ q
Driver Name: (called driver B in this document)1 K% ^* Y) |, [/ k
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In the afternoon of Nov. 7th, 2007, car B hit the back of car A.9 f G# D" a1 B, V% {* f
7 ]) k9 e4 s0 k! PThe driver B has paid; b* @" S9 ?* V! v7 W6 l
1. Bumper repair: $1 x7 N( ] D6 B! F
2. Other Compensation: $) P/ B# b7 q! P1 g& V" L* N$ d
9 O. f: I- G/ x" vdriver 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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" r/ m, `3 O+ K8 P9 HDriver A:
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Signature Date:& U( |2 v" w7 m4 q2 z6 x
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2 b; a, L8 \9 @8 iDriver B: I. o! n+ B' A! c4 X, v% `
3 T6 a: O; {0 e' }6 i( |Signature Date:# p# k( Y) Q% A4 D8 E0 b
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Witness:: d; o! ~& \. T
* L! i! a( g2 r) GSignature Date: |
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狗仔卡
发表于 2008-3-11 09:16
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