Creditor Statement Regarding

CREDITOR STATEMENT REGARDING

This Creditor Statement Regarding (the "Statement") is made as of Effective Date: by and between Creditor Name: with entity type: Corporation LLC Individual Other: and Debtor Name: .

RECITALS

WHEREAS, Creditor extended credit, goods, services, or other financial accommodations to Debtor under one or more agreements, including but not limited to the agreement identified as Account Number: , originally dated: (collectively, the "Obligations"); and

WHEREAS, Debtor is presently in default under the terms of the Obligations and Creditor asserts that as of the date set forth above there remains due, owing and unpaid a balance as set forth in this Statement; and

WHEREAS, Creditor desires to record and provide a formal written statement of the current account status, outstanding balance, security interests (if any), and other material information regarding the Obligations.

NOW, THEREFORE

NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. STATEMENT OF ACCOUNT

1.1 Creditor certifies, represents and warrants that the components of the unpaid Obligations as of Statement Date: are as follows: Principal amount: $; Accrued interest to date at the contract rate of from : $; Fees and costs: $; Total outstanding balance: $.

1.2 The foregoing totals reflect amounts due from Debtor to Creditor under the written records and accounting of Creditor. Creditor affirms that, to the best of its knowledge and reasonable investigation, no payments have been omitted and no offsets, counterclaims or credits have been applied other than those reflected above.

2. TRANSACTION AND COLLATERAL DETAILS

2.1 Original Obligation Reference: Agreement or Contract Reference: .

2.2 Lien perfection and public filing information, if applicable: UCC Filing Number: ; Filing Jurisdiction: ; Date of perfection: .

3. REPRESENTATIONS AND WARRANTIES

3.1 Creditor represents and warrants that it is the legal and beneficial owner of the Obligations or is the authorized agent or assignee with standing to assert the claims set forth herein, that the amounts stated above are true and correct as of the Statement Date, and that no other person or entity has a superior legal right to payment with respect to the amounts asserted other than as disclosed in writing in this Statement.

3.2 Creditor further represents that there are no credits, abatements, or offsets known to Creditor that would reduce the amount claimed except as expressly stated in Section 1.1. Creditor shall make available, upon reasonable written request by Debtor, original or copies of documents evidencing the Obligations, subject to any legally permissible redactions for privacy or security.

4. PAYMENT, APPLICATION AND ACCOUNTING

4.1 Payments received will be applied to the Obligations in accordance with the controlling agreement or, if no controlling agreement exists, in the following order: outstanding fees and costs, accrued interest, then principal. Creditor shall provide a written accounting summarizing application of any payment on request within thirty (30) days of receipt of such request.

4.2 Acceptance of any payment by Creditor shall not be construed as a waiver of rights to accelerate, pursue remaining amounts, or enforce any security interest, except to the extent expressly stated in a signed writing by Creditor.

5. DEMAND, ACCELERATION AND ENFORCEMENT

5.1 This Statement constitutes a formal demand for payment in full of the Total outstanding balance set forth in Section 1.1. Creditor reserves the right to declare all sums due and payable immediately upon any further default and to pursue all available remedies under the governing agreement, at law or in equity, including foreclosure, repossession, collection proceedings, and recovery of reasonable attorneys' fees and costs as permitted by law.

6. NOTICES

All notices required or permitted under this Statement shall be in writing and delivered to the addresses set forth below by hand, certified mail (return receipt requested), or nationally recognized overnight courier, and shall be effective upon receipt.

7. MISCELLANEOUS PROVISIONS

7.1 Governing Law. This Statement and any claim or dispute arising out of or relating to this Statement shall be governed by and construed in accordance with the laws of the State of without regard to its conflict of laws principles.

7.2 Entire Agreement. This Statement constitutes the entire written statement of the Creditor regarding the matters herein and supersedes any prior written or oral statements specifically concerning the amounts stated herein. To the extent there exists a controlling written credit agreement between the parties, this Statement is a supplemental statement of amounts due and does not modify the underlying substantive terms of such agreement unless expressly set forth in a separate written amendment signed by both parties.

7.3 Severability. If any provision of this Statement is held invalid or unenforceable, the remainder of this Statement shall remain in full force and effect and such invalid or unenforceable provision shall be reformed only to the extent necessary to make it enforceable while preserving intent.

7.4 Amendments; Waiver. No amendment, modification, or waiver of any provision of this Statement shall be effective unless in a writing signed by the party to be bound thereby. No failure or delay by any party in exercising any right shall operate as a waiver of such right.

7.5 Counterparts. This Statement may be executed in one or more counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Facsimile or electronically transmitted signatures shall be of the same legal effect as original signatures.

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