Claim Number 12-123456789
PROPERTY DAMAGE RELEASE
John Q Public for the sole consideration of $5,555.50 United States funds, in hand paid, receipt and sufficiency of which is hereby acknowledged, do hereby release, remise and forever discharge Jane Doe and their successors and assigns, heirs, executors, administrators, and all other persons, firms, and corporations (“Releasees”), of and from any diminished value to the 2012 Make Model resulting from a certain accident which happened on or about 01/01/2013 for which I have claimed the said Releasee(s) to be legally liable, which liability I acknowledge has been expressly denied. The release includes all elements of the property damage claims including loss of use and diminution of value, but this release does not include any personal injury claims.
I have full authority to execute a binding release of the above-referenced claim. I have not assigned this claim to anyone else. There is no guardian, trustee, executor, administrator, or other person or entity with power to approve or disapprove settlement of the above-referenced claim.
I do not have any bankruptcy petition currently pending. I understand that a false statement under oath pertaining to bankruptcy may result in denial of discharge from debts in bankruptcy, and federal criminal penalties of up to five years in prison, a $5,000 fine, or both.
NOTICE & ACKNOWLEDGEMENT:
I understand and agree that the consideration stated is paid by the liability insurance carrier for a party released hereby. I have been informed, prior to executing this instrument, that the payment is made by the insurance carrier as an independent contractor without consent to settle on behalf of any person released hereby, and that payment to the undersigned shall have no effect upon, nor preclude any claims, if any, by any party released against the undersigned or those through whom the undersigned, make claim. I hereby acknowledge the foregoing notice, furnished in accordance with Georgia law, and also receiving a copy of this instrument.
Signed this________ day of ____________________, 20____ .