ACKNOWLEDGMENT OF GRATUITY PAYMENT
DATE: _________
COMPANY NAME: ____________________________________
ADDRESS: ____________________________________________
I, Name: _____________________________________________________________ of address
____________________________, do hereby affirm as follows:
I acknowledge that the ride offered by __________________ was FREE.
I acknowledge that I have paid the sum of $_______________ (hereinafter “payment”) to
___________________________________.
I acknowledge that the payment is GRATUITY and DOES NOT amount to any payment for
any services rendered by _____________________.
I acknowledge that I made the payment out of my own volition.
This Acknowledgement and/or Affirmation shall be construed broadly to constitute a binding
document to the maximum extent permissible under applicable law.
I acknowledge and represent that: (a) I have read this entire Acknowledgement; (b) I understand
the averments herein; and (c) I understand that by signing below, I am executing a binding
document.
I CERTIFY THAT I HAVE READ THIS DOCUMENT CAREFULLY, THAT I
UNDERSTAND ITS TERMS AND ITS EFFECT CLEARLY, AND THAT I HAVE SIGNED
THIS DOCUMENT VOLUNTARILY AND WITHOUT COERCION.
SIGNATURE:_________________________________________ DATE:________________
PRINT NAME: _________________________________________
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