To ______________________[Creditor] of _________________________________________________[address].
I__________________________ [Debtor]
Address______________________________________
I hereby acknowledge that I am indebted to you in Rs__________________________ being___________________[number of years] years’ arrears of interest at the rate of__________ percent secured by mortgage dated ___________________ and made between _______________________________________[parties] or payable in respect of a judgement of the court dated _______________________ in an action conveyed to me by you on the________________________ day of
____________________________.
Signature: __________________[Debtor]

Date: