Debtor Acknowledgment Form

DEBTOR ACKNOWLEDGMENT FORM

This Debtor Acknowledgment is made by Debtor Name: , Debtor Address: , in favor of Creditor Name: , Creditor Address: .

RECITALS

WHEREAS, Debtor acknowledges that Debtor is indebted to Creditor in the principal amount of $ under that certain agreement or obligation described as: (the "Obligation"), originally dated .

WHEREAS, Debtor has reviewed the terms and admits that the Obligation is valid, enforceable, and presently due or subject to acceleration as set forth herein.

WHEREAS, the parties desire to set forth in writing Debtor's acknowledgment and certain covenants and consents in respect of the Obligation.

NOW, THEREFORE

In consideration of the mutual covenants set forth below and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. ACKNOWLEDGMENT OF DEBT

Debtor hereby acknowledges, certifies, and confirms that the Obligation identified above is due and owing to Creditor in the principal sum of $, together with accrued interest, fees, and other charges as permitted under the Obligation and applicable law. Debtor expressly waives any defenses based on lack of notice, failure to present, non-performance by Creditor, or any other claim that accrued prior to the date of Debtor's signature below, except as expressly reserved in this instrument.

2. PAYMENT TERMS

The current payment schedule and terms are:

Interest rate applicable to the outstanding balance is per annum, computed as provided in the Obligation. Maturity date (if any): .

3. SECURITY AND COLLATERAL

To secure payment of the Obligation, Debtor acknowledges that the Obligation is secured by the following collateral, if any:

Debtor authorizes Creditor to take any actions necessary to perfect, continue, or enforce any security interest or lien, including the filing of financing statements or analogous instruments, without further consent from Debtor, to the extent permitted by law.

4. REPRESENTATIONS AND WARRANTIES

Debtor represents and warrants that: (a) Debtor has full power and authority to enter into this Acknowledgment; (b) this Acknowledgment constitutes a valid and binding obligation of Debtor enforceable in accordance with its terms; (c) no offset, defense, counterclaim, or right of setoff exists with respect to the Obligation other than those disclosed in writing to Creditor contemporaneously with execution of this Acknowledgment; and (d) the information provided in this Acknowledgment is true and accurate as of the date of execution.

5. DEFAULT; REMEDIES

An Event of Default shall include Debtor's failure to perform any payment obligation when due, any representation or warranty breach, insolvency, or appointment of a receiver for Debtor. Upon default, Creditor may accelerate the Obligation and pursue all remedies available at law or in equity, including collection, foreclosure, repossession, and recovery of reasonable attorneys' fees, court costs, and collection expenses to the extent permitted by law.

6. WAIVER OF JURY TRIAL; VENUE

To the maximum extent permitted by law, Debtor and Creditor each waive any right to a jury trial in any action arising out of or relating to this Acknowledgment. The parties agree that exclusive venue for any litigation arising hereunder shall be in the courts located in the jurisdiction identified in Section 12.

7. NOTICES

All notices, demands and other communications required or permitted hereunder shall be in writing and shall be deemed given when delivered personally or three (3) days after deposit with the postal service by certified mail, return receipt requested, to the addresses set forth below or to such other address as a party may designate by notice to the other party in accordance with this Section.

8. AMENDMENTS; WAIVER

This Acknowledgment may be amended or modified only by a written instrument signed by both Debtor and Creditor. No failure or delay by Creditor in exercising any right shall operate as a waiver; any waiver must be in writing and signed by the waiving party.

9. GOVERNING LAW; JURISDICTION

This Acknowledgment shall be governed by and construed in accordance with the laws of the jurisdiction of Governing State: without regard to conflict of laws principles. The parties submit to the exclusive jurisdiction and venue of such courts.

10. ENTIRE AGREEMENT; SEVERABILITY

This Acknowledgment, together with the Obligation and any instruments referred to herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision of this Acknowledgment is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. COUNTERPARTS; EXECUTION

This Acknowledgment may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Signatures delivered by electronic means shall be deemed original signatures for all purposes.

12. ADDITIONAL ACKNOWLEDGMENTS

Debtor further acknowledges that Debtor has received a complete and legible copy of the Obligation and has had the opportunity to consult with independent counsel. Debtor expressly consents to the collection and reporting of payment information to credit reporting agencies in accordance with applicable law.

I have received a true and complete copy of the Obligation.
I have had an opportunity to consult with legal counsel regarding this Acknowledgment.
I assert no valid offsets or defenses other than those disclosed in writing to Creditor.

13. ADDITIONAL INFORMATION

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