Fill and Sign the Agreement for Accord and Satisfaction of an Undisputed Form

Agreement for Accord and Satisfaction of an Undisputed Hospital ClaimAgreement made on _______________________ (date) between ________________________________ (Name of Creditor), a corporation organized and existing under the laws of the state of __________________ (name of state), with its principal office located at _______________________________________________ ________________________________________ (street address, city, state, zip code), referred to herein as Creditor, and _______________________ (Name of Debtor), of _____________________________________________________________________ (street address, city, state, zip code) , hereinafter referred to herein as Debtor. For and in consideration of the mutual covenants contained in this Agreement, and other good and valuable consideration, the parties agree as follows: I. Acknowledgment of Existing Obligation The parties acknowledge that Debtor is at present indebted to Creditor in the amount of $_____________, for hospitalization and treatment from _______________ (date) to ___________________ (date). II. Agreement for Different Method of Payment A.Creditor acknowledges that a lump sum payment of said amount of $ _______________ would result in severe financial problems for Debtor. Creditor further acknowledges that it would prefer to have a lump sum payment rather than having Creditor making payments over several years. B. Debtor and Creditor desire, and they hereby agree, to provide for satisfaction of the above-stated indebtedness in accordance with terms and provisions different from Section I above, and in substitution of the said terms and provisions for payment. III. Consideration A. Method of PaymentDebtor agrees to pay to Creditor, and Creditor agrees to accept from Debtor, in full satisfaction of the indebtedness described in Section I, above, a lump sum payment of $_____________, in full satisfaction of the debt described in Section I above. Said amount shall be paid by Debtor to Creditor on or before ________________ (date). B. Default by Debtor: Time is declared to be of the essence in this Agreement; and if Debtor should fail to make said lump sum payment on or before _________________ (date), then Creditor is released forever from its obligation to accept from Debtor the lesser sum of $_____________, and shall have no further obligations under this Agreement. C. Satisfaction: On full payment by Debtor to Creditor of the amount set forth in Subparagraph A of this Section III on or before (date), the original indebtedness of Debtor to Creditor, as described in Section I above, and said indebtedness, shall forever be cancelled and discharged. Witness our signatures this the _____ day of ______________, 20____. (Name of Creditor) By_________________________ ______________________ (Signature of Officer) (Signature of Debtor) _______________________________ ______________________ (Printed Name of Officer and Office) (Printed Name of Debtor) (Acknowledgements may vary by state) STATE OF _______________ COUNTY OF _____________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of __________, 20____, within my jurisdiction, the within named _________________________ (Name of Officer), who acknowledged that he is ____________________ (Name of Office) of _________________________ (Name of Corporation), a ___________________ (name of state) corporation, and that for and on behalf of the said corporation, and as its act and deed he executed the above and foregoing instrument, after first having been duly authorized by said corporation so to do. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________ State of _____________________ County of ___________________ Personally appeared before me, the undersigned authority in and for the said County and State, on this __________________ (date), within my jurisdiction, the within-named ___________________________ (Name of Debtor), who acknowledged that he executed the above and foregoing instrument. ________________________________ NOTARY PUBLIC My Commission Expires: