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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
, S; c Q1 P% H# o' c0 L$ sFinal Settlement+ S- s* ?0 P- @8 r) n* U3 J% a
# \. Y f6 x8 b* f W( G. _CAR A:7 s3 z, S! ~- D+ `% g- C2 u& T6 X
Year -
5 b/ x& p+ M& TMaker/Model -
4 C/ C7 ~6 s9 j$ Q6 _; U% [ u) A9 KSerial (VIN) # -
& T: u: P% Z; _7 {: m9 P5 }% p i% X. aPlate Number:
( f& f3 I* D( s9 d* K( ^; X4 r3 [/ RDriver Name: (called driver A in this document)% C* }3 C( ?3 [, T6 f
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CAR B:
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Maker/Model –
* m! g8 k. j5 q+ }( i1 D! bSerial (VIN) # -
! l' F8 V( i9 k. ]* ^4 K; UPlate Number:
9 x$ u# D( z. K+ C. P! VDriver Name: (called driver B in this document) C* T+ Y7 v0 T
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In the afternoon of Nov. 7th, 2007, car B hit the back of car A.% T+ B* r' m; {0 J ^; G
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The driver B has paid
7 Y8 l4 y2 m* F+ l U1. Bumper repair: $- k" k* H: G) P) t2 m, s
2. Other Compensation: $2 i1 d0 x8 K( L- V- V
9 ^' Y( r9 a7 @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.! H. X9 o3 K. U. J
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Driver A: H% A q- y2 p- v3 ^+ }
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Signature Date:, Q: T6 c. M% f4 E* ~
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) V6 l: ^9 T( q" O! n z: c% XDriver B:
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# e8 o0 T2 Q5 `Signature Date:
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Witness: F& d3 Z" F! L- U1 L0 ?( t
6 ]2 S3 [# V9 q& ] \Signature Date: |
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狗仔卡
发表于 2008-3-11 09:16
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