I ______________________________[Debtor].
Residing at ___________________________________________________________________
Creditor _____________________________________

I ________________________________________________[Debtor] hereby acknowledge that _________________________________ has the day advance to me the sum of ____________________________________ by the way loans (free of interest or bearing interest at ______________________percent annum/payable half yearly on _______________________________and ________________________________in earn year or the date of payable or as case may) .
I agree to repay the same to _________________________[creditor].
Signature : _______________________ [Debtor]

Date :