Please fill out the following form.
Please print your completed form if you would like to have a copy for your records.

FOR VALUE RECEIVED, the undersigned hereby assigns and transfers to (Name of the person or the company receiving the rights) all rights, title and interest in and to the account(s)receivable described as follows :

DESCRIPTION OF THE ACCOUNTS RECEIVABLES BEING Transferred

The undersigned warrants that the said account(s) are just and due and the undersigned has not received payment for same or any part thereof and has no knowledge of any dispute thereon; provided, however, that said account(s) are sold without recourse to the undersigned in the event of non-payment.

The undersigned further warrants that it has full title to said receivables, full authority to sell and transfer same, and that said receivables are sold free and clear of all liens, encumbrances or any known claims against said account(s).

This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

Signed this day of :

_____________________

Signed in the presence of :

Witness :