5/23/2018 Church of Scientology: Four Quadrillion Year Waiver

1/3

RELEASE WAIVER AND WRIT OF EXPULSION1. I, , have requested a repayment of donationsI have made to the Church of Scientology Flag Service Organization,

Inc.2. In exchange for checks in the amount of . and $and on receipt of these repayments, I release and waive all claims fordamages, injuries or losses sustained of any kind or nature, whetherknown or unknown, which I may have from the beginning of time upto and including this day against the Church of Scientology FlagService Organization Inc., its officers, trustees agents,representatives, servants, employees, volunteers, directorspredecessors, successors, licensees, licensors, assigns and

beneficiaries; and for each individual, his or her heirs, successors,representatives, assigns. beneficiaries, executors, and administratorshereinafter referred to collectively as Released Parties).3. I know and understand that as a condition of receiving thereturn of donations made to any Church of Scientology, that I will nolonger be qualified to receive any or participate in any additionalScientology religious services, either religious training or auditing(Scientology religious counseling) from or through any Church of

Scientology.4. I understand that this release and waiver signifies settlement ofclaims and does not constitute an admission by any of the ReleasedParties of any wrongdoing and that such Released Parties expresslydeny the validity of such claims.5. I acknowledge and affirm that I have carefully read this releaseand waiver and that I sign it of my own free will without any duressfrom the Released Parties or anyone else.

Initials Initials

Page 1 of2

5/23/2018 Church of Scientology: Four Quadrillion Year Waiver

2/3

6 I acknowledge and affirm that I am not under the influence ofany drug, narcotic, alcohol or other mind-influencing substance,condition or ailment such that my ability to fully understand themeaning of this release and waiver and the significance thereof wouldbe adversely affected.3 In the event any provision hereof be unenforceable, suchprovision shall not affect the enforceability of any other provisionhereof.

Date

Witness Print Name) Witness Signature)

Initials Initials

Page 2 of

5/23/2018 Church of Scientology: Four Quadrillion Year Waiver

3/3