 鲜花( 3)  鸡蛋( 0)
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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
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0 h$ ?: \: q( _8 Q( K% C! aCAR A:
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Maker/Model -
" a& v4 l; m$ {7 [( KSerial (VIN) # -
! }/ Y0 v0 u6 B$ m) wPlate Number:
" J0 z7 u+ u) `7 I* Y! P" ?. _Driver Name: (called driver A in this document)
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CAR B:* ^& G8 G* u3 t3 ?7 D4 W
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Maker/Model –3 |( t; @+ x6 W% o1 n, G6 p
Serial (VIN) # -
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Driver Name: (called driver B in this document)
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In the afternoon of Nov. 7th, 2007, car B hit the back of car A.
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" ]! R* D. i Q* M/ G$ K& nThe driver B has paid
4 K* F0 H' o8 u- `2 W' j g1. Bumper repair: $4 [$ e0 U' W. E1 U9 @1 X% ?
2. Other Compensation: $
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, G) b! b, m) K t- B. a! idriver 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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* o- x( R- s9 z0 G& `Signature Date:
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* M& a+ I7 I$ f9 m2 l5 R! x/ Y+ XDriver B:
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% C- g( C. {6 pSignature Date:
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Witness:( j" x# c( y4 g2 H
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Signature Date: |
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