Know all men by these presents: That I, A. B., of---------, in consideration of the sum of --------- dollars ($--------), received to my full satisfaction of the C. D. Street Railway Company, do for myself, my executors, administrators and assigns, hereby release and forever discharge said the €. D. Railway Company, together with its successors and assigns, from all debts, claims, demands, damages, actions, and causes of action whatsoever, and including such as have arisen by reason of, or in any manner grow out of --------- [state foundation of claim, as "the injuries received by me on ---------, 19-, at---------, while crossing

--------- Street, by being struck by a street car operated by employes of said the C. D. Street Railway Company"]. In witness whereof, etc.

See references under Sec. 3837.