_____________, 19__ 

                In consideration of _____________________________ 
        to _______________ paid by ___________________ the 
        receipt whereof is hereby acknowledged _______ hereby remise, 
        release and forever discharge the said ___________________ 
        of and from all debts, demands, actions, causes of action, suits, 
        accounts, covenants, contracts, agreements, damages, and any and 
        all claims, demands and liabilities whatsoever of every name and 
        nature, both in law and in equity, which against the said 
        ________________ or _______________ heirs and 
        assigns __________________ now have or ever had from the 
        beginning of the world to this date and more especially on 
        account of __________________________________________________.  

        Witness ____________ hand and seal
        Signed in the presence of 

        ___________________________________       _______________________ 

                                                        Form 614 


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