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DEBT ACKNOWLEDGEMENT
The undersigned hereby confirms and acknowledges to
(Creditor) that the undersigned is indebted to the Creditor in the amount of $
as of date hereof, which amount is due and owing and includes all accrued interest and other
permitted charges to date. We further acknowledge that there are no defenses to, or credits or
rights of set off as against said account balance and that the Creditor shall be authorized to enter
a confession of judgment (where so allowed by law) against the undersigned for the amount of
debt acknowledged to be due.
Signed this day of , (year).
Signed in the presence of:
____________________________________ ___________________________________
Witness Debtor