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]