Appendix A to Part 625 - Dependent Travel Waiver of Liability

Appendix A to Part 625 - Dependent Travel Waiver of Liability

“I _____________________

(Name of dependent)

will be accompanying _____,

(Name of employee)

who is my _________________

(Relationship)

and who is an employee of _____,

(Agency, division)

on official Government business in or while using a Government vehicle. Dates of travel are from _____ to _____ 19__. I do hereby knowingly, freely and voluntarily waive any right or cause of action of any kind whatsoever, against the United States, arising as a result of such activity from which any liability may or could accrue while accompanying the above employee in or while using said Government vehicle.”

Signature of dependent

Notary Public

Date

Date