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DEBT ACKNOWLEDGEMENT FORM
TEMPLATE

Amount:
_________________________________
Place: _________________________________________

Date:

_________________________

I Mr. ABC, make commitment to pay XYZ Company, the Sum of
$ ________________________. Repayment is to be made in
the form of 200 equal payments at the interest rate of 7.2% of
$ _____________ payable on the 1oth of each month,
beginning 10/01/2011 until the total amount of debt is paid.

IN WITNESS WHEREOF, I set my hand under seal this ____ [the day] of
__________________ [month], 20___ and I acknowledge receipt of a
completed copy of this instrument.

_____________________
Sign: [Signature of borrower]

________________________________
Name & Address: [Party name]

Notary Public - SEAL
My Commission Expire
______/______/______