Fill and Sign the Agreement Disputed Form

Agreement to Arbitrate Disputed Open Account Agreement made on the       day of       , 20       , between       of       , (Name of Creditor) (Street Address, City, County, State, Zip Code) referred to herein as Creditor, and       , of (Name of Debtor)       , referred to herein as Debtor. (Street Address, City, County, State, Zip Code) Whereas, a dispute has arisen between Debtor and Creditor as to the amount owed by Debtor to Creditor resulting from a series of transactions between the parties; and Whereas, the transactions are in connection with an open account between the parties; and Whereas, the Debtor's memorandum of these transactions is attached as Exhibit A attached hereto and incorporated by reference; and Whereas, the Creditor's memorandum of these transactions is attached as Exhibit B and incorporated by reference; Now, therefore, in order to settle the dispute amicably and to avoid litigation as to any dispute, the parties agree as follows: 1. Submission of Dispute to Arbitration. The dispute as to the open account will be settled by arbitration. 2. Arbitration to be Binding. The amount owed by Debtor to Creditor on the open account set forth in the finding of the Arbitrator named here will be binding on Debtor and Creditor. 3. Appointment of Arbitrator.       (Name and Title of Arbitrator)       is appointed by Debtor and Creditor as Arbitrator to (Address of Arbitrator) settle the disputed open account. 4. Expenses of Arbitration. Expenses of the Arbitration will be borne equally by the parties as follows: Debtor will pay one-half of the expenses and Creditor will pay one-half of the expenses. Each party will pay the fees of that party's own witnesses who are called to appear before the Arbitrator. 5. Authority of Arbitrator. The Arbitrator named here will have the right and power to fix hearing dates in the arbitration, and to subpoena and swear witnesses before testifying, as provided by law. 6. Effectuation the Decision of Arbitrator. Debtor agrees to make, and Creditor agrees to Agreement to Arbitrate Disputed Open Account Page 1 of 2 accept, any payment or payments as may be necessary to settle the disputed account as found by the Arbitrator. The parties further agree to execute instruments and perform any acts necessary to effect a settlement, as found by the Arbitrator. 7. Number of Copies. This Agreement is executed in triplicate originals, each party to retain one, and one to be delivered to the Arbitrator for the Arbitrator's use. 8. Severability. The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 9. No Waiver. The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 10. Governing Law. This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of       . (Name of State) 11. Notices. Unless provided herein to the contrary, any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified or registered mail if sent to the respective address of each party as set forth at the beginning of this Agreement. 12. Entire Agreement. This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 13. Modification of Agreement. Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. WITNESS our signatures as of the day and date first above stated. By: By: (Signature of Creditor) (Signature of Debtor)             (P rinted Name of Creditor) ( P rinted Name of Debtor) Agreement to Arbitrate Disputed Open Account Page 2 of 2