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                  | DEBT ACKNOWLEDGEMENT FORM 
 
 
 
 
 I, ____________________________________________ the undersigned, hereby confirm and
 
 
 
 acknowledge to the following Creditor _____________________________________________
 
 
 
 that I am indebted to said Creditor, in the amount of $ ______________________ dollars as of
 
 
 
 the below mentioned date.  The indebted amount includes any and all legally permitted
 
 
 
 charges such as accrued interest, up to that same below mentioned date.
 
 
 
 I furthermore acknowledge that I have no argument with said debts which were incurred by
 
 
 
 myself, and for which I am solely responsible.  This also means that I acknowledge that
 
 
 
 there are no defenses should said Creditor decide to use this legal form in a court of law as
 
 
 
 a confession to judgment - where legally permissible.
 
 
 
 Signed on this _______ day, of the month ______________________in the year ____________.
 
 
 
 
 
 
 
 ______________________________________________________
 
 Witness
 
 
 
 ______________________________________________________
 
 Debtor
 
 
 
                       
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