Fill and Sign the Know All Men by These Presents that I for and in Consideration Form

ABSOLUTE RELEASE OF ALL CLAIMS KNOW ALL MEN BY THESE PRESENTS that in consideration of the sum of $_______________ , cash in hand paid, the receipt of which is hereby acknowledged, for myself, my heirs, personal representatives and assigns, I do hereby release, acquit and forever discharge ______________ , and _________________ from any and all claims, demands, actions, rights, benefits and suits, including any claim for medical expenses which I may now or hereafter have under the Mississippi Workmen's Compensation Act or otherwise, on account of my sustaining accidental injuries growing out of my employment with _________________, in ___________- County, Mississippi.I hereby agree that as further consideration and inducement for this compromise settlement that this settlement shall apply to unknown and unanticipated injuries and damages resulting from said accident as well as those now disclosed. This Release shall also apply to any and all claims of whatsoever nature arising out of my employment, including reemployment rights.This Release is signed by ________________, pursuant to an Order of the Mississippi Workmen's Compensation Commission, dated _____________, authorizing settlement of this claim under Section 9 (i) of the Mississippi Workmen's Compensation Act, as amended.WITNESS MY SIGNATURE, this the _______ day of ____________, 20___ . ** CLAIMANT STATE OF MISSISSIPPI COUNTY OF _____________ Personally appeared before me, the undersigned authority, ____________ , who acknowledged that signed and delivered the above Release on the day and year therein mentioned.GIVEN UNDER MY HAND AND SEAL OF OFFICE, this the ______ day of _____________, 20______ . NOTARY PUBLIC My Commission Expires: