I,_____ 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 owing includes all accrued interest and other permitted charges to date. We further acknowledge that there are no defence to, or credits or rights of set off as against balance and that the creditor shall be authorize to enter a confession of judgment against the undersigned for the amount of debt acknowledged to be due.
 
Signed this on____ day of ___ 20___
 
Signature of Debtor: