I, ________________(Name of the Debtor) hereby confirm and acknowledge to_______________(Name of Creditor), hereinafter called Creditor, that I am indebted to said Creditor in the amount of __________ as of the date set forth below. I acknowledgment and agree that I incurred said Debt and I am solely responsible for repayment of it to Creditor.

I have promised and agreed to pay the entire amount by____________(date), and I will pay a least________of the amount of said debt on or before the __________ (date) of each month beginning ___________ (date), until it is paid. I have agreed that the entire amount of said Debt will be paid on or before__________ (date).

This agreement has been signed on this date the ___ day of ____ in the year 20__.

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