Form Sr-59 - Conditional Release - Alabama Department Of Public Safety
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1Alabama Department of
Public Safety
Conditional Release
To be executed when parties have agreed on payment by installments. In case of default, A SECOND CONDITIONAL
RELEASE WILL NOT BE ACCEPTED. If the notarized release is obtained from the insurance company of the
claimant, a subrogation or proof of loss must be furnished. Release need not be notarized if properly witnessed by two
OTHER persons over eighteen years of age. Witnesses' complete addresses must be furnished.
The following agreement entered into this ______________ day of ___________________, 20____, between
_______________________________________________________________________________, person making claim,
and _______________________________________________________________________, person making payment.
Now, whereas the person making the claim received damages, property and/or personal injuries, in the amount of
$____________________ due to the motor vehicle accident which occurred on (Date) _________________________ at
(City or County)_________________________________________.
THEREFORE, the following duly acknowledged written agreement providing for the payment of the above agreed amount
in installments is herewith executed in accordance with Title 32-7-7 (4). Code of Alabama.
1. The person making payment hereby agrees to pay the person making claim the sum of $_____________ on the
__________________ day of each ______________________ beginning ________________________,
20_____, and to continue such payment until the above agreed amount has been paid in full.
2. The person making the claim in consideration of the above described payments, hereby expressly releases the
person making payment from further compliance with the security provisions of the Motor Vehicle Safety
Responsibility Act.
3. Both parties hereby agree that the Department of Public Safety may use the agreement in processing this
accident, subject to the provision of the laws as to default in payment of any installment. Title 32-7-8 (3). Code of
Alabama.
Witness whereof, we have hereunto set our hands and seals this ________ day of ____________________, 20____.
WITNESS 1:
________________________
______________________________
________________________________
NOTARY FOR PERSON
PERSON MAKING CLAIM
Witness Signature
MAKING CLAIM
(Or Attorney)
________________________________
Address
________________________
________________________________
My Commission Expires
City, State, Zip Code
WITNESS 2:
________________________
______________________________
________________________________
NOTARY FOR PERSON
PERSON MAKING PAYMENT
Witness Signature
MAKING PAYMENT
(Or Attorney)
________________________________
Address
________________________
________________________________
My Commission Expires
City, State, Zip Code
SR-59
Rev. 03/06
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