To ______________________

Notice is hereby given that the undersigned, ____________________, rescinds that certain release executed by him on _____________ (date) , whereby he released you from any and all claims arising out of __________________ (subject for which release was executed), on the following grounds: _____________________________________________________________________________

The undersigned agrees to restore to you total consideration received by you for his execution of the release, including ______________________ (consideration received).

Dated: ___________________

______________________________

(Signature)