General Affidavit and Release Form

GENERAL AFFIDAVIT AND RELEASE FORM

This General Affidavit and Release Form is made as of by and between Affiant Name: of Address: (hereinafter "Affiant"), and Releasee Name: of Address: (hereinafter "Releasee").

Recitals

WHEREAS, Affiant asserts certain facts and circumstances relating to the incident described as:

WHEREAS, Affiant alleges that the event occurred on or about and that certain claims, damages, losses, or causes of action may have arisen as a result; and

WHEREAS, in consideration of the promises, covenants and express release set forth herein, the parties desire to settle, release and resolve all disputes, claims and causes of action that Affiant has, may have, or might assert against Releasee related to the matters described above.

Now, Therefore

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Definitions

For purposes of this Agreement, the following terms shall have the meanings set forth below. "Claims" shall mean any and all claims, demands, actions, causes of action, liabilities, obligations, losses, damages, costs, and expenses (including reasonable attorneys' fees) whether known or unknown, suspected or unsuspected, asserted or unasserted, arising out of or in any way connected with the facts alleged in the Recitals or the incident described in the incident description field above.

2. Affidavit of Facts

Affiant hereby certifies under penalty of perjury that the statements made in this document and in any attachments hereto are true and correct to the best of Affiant's knowledge, information and belief. Affiant declares the following facts are true and accurate:

Affiant understands that making a false statement in this Affidavit may subject Affiant to penalties for perjury under applicable law.

3. Release and Waiver

In consideration of the foregoing and other good and valuable consideration, Affiant, on behalf of Affiant and Affiant's heirs, executors, administrators, successors, and assigns, hereby irrevocably and unconditionally releases, acquits, and forever discharges Releasee and Releasee's past, present and future officers, directors, employees, agents, insurers, attorneys, representatives, subsidiaries and affiliates (collectively, the "Released Parties") from any and all Claims arising from or related to the facts set forth in this Affidavit, whether known or unknown, which Affiant now has or may hereafter have against the Released Parties.

This Release includes, without limitation, any Claims for personal injury, property damage, emotional distress, negligence, breach of contract, statutory violation, or other cause of action arising from the matters described herein.

4. Consideration

As full and complete consideration for the promises and releases contained herein, Releasee shall provide the following consideration to Affiant:

If monetary consideration is provided, amount:

5. Representations and Warranties

Affiant represents and warrants that Affiant has the full power, authority, and legal capacity to execute and deliver this Affidavit and Release and to perform Affiant's obligations hereunder, and that the execution and performance of this Agreement will not violate any provision of law, contract, order, or agreement to which Affiant is bound.

6. Indemnification

Affiant agrees to indemnify, defend and hold harmless Releasee from and against any and all Claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising out of or relating to any breach of the representations, warranties or covenants made by Affiant in this Agreement, or any untrue or misleading statement made by Affiant in this Affidavit.

7. Confidentiality

Except as required by law, the parties agree that the existence and terms of this Agreement shall remain confidential and shall not be disclosed to any third party without the prior written consent of the other party, provided that Releasee may disclose this Agreement to its professional advisors or as required by law.

8. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to its conflict of law provisions.

9. Entire Agreement

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, negotiations, representations, understandings and communications, whether written or oral.

10. Severability

If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, the remaining provisions shall remain in full force and effect and such invalid, illegal or unenforceable provision shall be reformed to the extent possible to reflect the parties' original intent.

11. Notices

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below, or to such other address as either party may designate by notice in accordance with this Section.

12. Amendments and Waiver

No amendment, modification or waiver of any provision of this Agreement shall be effective unless it is in writing and signed by both parties. No failure or delay by either party in exercising any right hereunder shall operate as a waiver thereof.

13. Counterparts

This Agreement may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument. Signatures delivered by electronic means shall be deemed original signatures for all purposes.

14. Execution and Acknowledgment

Affiant acknowledges that Affiant has read and understands the terms of this Affidavit and Release, has had the opportunity to consult with independent counsel, and signs this Agreement voluntarily and with full knowledge of its legal significance.

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