Fill and Sign the Amount Claim Form

Agreement for Accord and Satisfaction with Amount of Claim Undetermined 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) 1. Basis of Debt. Creditor, over a number of years, has advanced moneys to Debtor in various amounts and at various periods of time, commencing on       , up to and (Date) including       , the total amount of which cannot be determined because of the (Date) insufficiency or inadequacy of the records of both parties. 2. Settlement. The parties desire to make a complete and final settlement between them of their accounts. 3. Amount to be Paid. It is agreed that Debtor shall pay to Creditor $       , and Creditor shall accept this amount, in full and complete satisfaction of the indebtedness of Debtor resulting from the advances mentioned above. 4. Payment Schedule. Debtor shall make payment to Creditor of the above-mentioned amount by payment in cash on or before       . (Date) 5. Effect of Full Payment. On full payment by Debtor to Creditor of $       , as provided above, the original indebtedness of Debtor to Creditor, resulting from the advances described in Section 1 above, shall forever be cancelled and discharged. WITNESS our signatures as of the day and date first above stated. By: By: (Signature of Debtor) (Signature of Creditor)             (P rinted Name of Debtor) (P rinted Name of Creditor) Agreement for Accord and Satisfaction Page 1 of 1