Settlement Disclosure
Final Settlement
CAR A:
Year -
Maker/Model -
Serial (VIN) # -
Plate Number:
Driver Name:
CAR B:
Year -
Maker/Model
Serial (VIN) # -
Plate Number:
Driver Name:
TIME OF ACCIDENT HAPPENED:
LOCATION OF ACCIDENT HAPPENED:
DISCRIPTION OF ACCIDENT HAPPENED:
The driver B has paid
1. ............ repair: $
2. ............ repair: $
3. ............ repair: $
4. ............ repair: $
5. Other Compensation: $
to driver A to make a final and permanent settlement of this accident. Driver A has received the above amount of money. And Driver A agrees to 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.
Driver A:
Signature: Date:
Driver B:
Signature: Date:
Witness:
Signature: Date:
Final Settlement
CAR A:
Year -
Maker/Model -
Serial (VIN) # -
Plate Number:
Driver Name: (called driver A in this document)
CAR B:
Year -
Maker/Model
Serial (VIN) # -
Plate Number:
Driver Name: (called driver B in this document)
In the afternoon of xx xx, 200X, car B hit the back of car A.（注：车祸描述，
简短即可，不必一定写明谁的责任）
The driver B has paid
1. Bumper repair（或者其它什么）: $
2. Other Compensation: $
to driver A to make a final and permanent settlement of this accident. Driver A has received the above amount of money. And Driver A agrees to 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.
Driver A:
Signature
Date:
Driver B:
Signature
Date:
Witness:
Signature
Date: