Debt Acknowledgment Form

I, ________, hereby confirm and acknowledge that I owe an individual, named ________, the following amount of money: $________ (________).

This amount is owed as of the date set forth below. This amount includes all accrued interest and other miscellaneous, allowed charges to date.

I further acknowledge that there are no defenses to the amount owed or any credits or set-offs against the amount owed.

________ shall be authorized to enter any confessions of judgment where permitted by law against me for the amount owed.

I hereby promise to pay the entire amount listed herein by the ________.

EXECUTION:

Name Of Debtor: ________

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Signature

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Date

State of Alabama

County of: ______________________________

On this _____ day of ________________________________________, 20__, before me, personally appeared _____________________________________________, to me known to be the person described in and who executed the foregoing instrument, and acknowledged that they executed it as their free act and deed.

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Notary Signature, Printed Name, and Notary/Bar Roll Number

Name Of Creditor: ________

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Signature

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Date