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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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3/28/2013
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