Debtor's Statement Form

DEBTOR'S STATEMENT FORM

This Debtor's Statement Form (the "Statement") is made and entered into on Date: between Creditor Name: and Debtor Name: concerning Account Number: .

RECITALS

WHEREAS, Creditor maintains records reflecting charges, payments and adjustments relating to the Account and asserts that, as of the Effective Date, there exists an outstanding obligation owing by Debtor to Creditor; and

WHEREAS, Debtor desires to provide a written statement of the Debtor's financial condition, the status of the Account, and a proposed arrangement for resolution of the outstanding obligation, and Creditor requires same for review and potential acceptance; and

WHEREAS, the parties intend that this Statement set forth certain facts, acknowledgments and agreements relating to the Account and the parties' rights and obligations.

NOW, THEREFORE, in consideration of the mutual covenants contained in this Statement and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. STATEMENT OF ACCOUNT

Debtor hereby acknowledges and certifies that as of the Effective Date the principal, interest, fees and other charges due and owing on the Account aggregate to the sum of $ (the "Outstanding Balance"). This amount reflects Debtor's good faith computation and is subject to verification against Creditor's records.

2. PAYMENT HISTORY

Debtor states that payments made on the Account since origination are described as follows (include dates, amounts, and method of payment):

Last Payment Date: Amount of Last Payment: $

3. DEBTOR FINANCIAL STATEMENT

Individual    Business

Has Debtor been a party to a bankruptcy, insolvency, or similar proceeding? Yes    No

4. PROPOSED PAYMENT ARRANGEMENT

Debtor proposes to pay Creditor as follows:

Proposed First Payment Date:    Debtor agrees to make payments by:

Late payment interest and charges will accrue and be applied in accordance with the original agreement and applicable law. Debtor acknowledges that failure to make payments as proposed may result in acceleration of the Outstanding Balance and enforcement of Creditor's rights.

5. REPRESENTATIONS AND WARRANTIES

Debtor represents and warrants to Creditor that: (a) the information provided in this Statement is true, complete and correct to the best of Debtor's knowledge; (b) there are no other material obligations or encumbrances affecting the assets disclosed other than those listed herein; and (c) Debtor has authority to execute this Statement if signing in a representative capacity. Debtor acknowledges that any material misrepresentation may constitute default and grounds for immediate collection action.

6. AUTHORIZATION TO VERIFY

Debtor authorizes Creditor and its agents to obtain such credit reports, employment verification and other information as Creditor deems necessary to verify the information contained in this Statement. Debtor further authorizes third parties to release such information to Creditor upon request. This authorization shall remain effective until the Outstanding Balance is satisfied or otherwise resolved in writing.

Debtor expressly consents to the above authorization.

7. REMEDIES AND DEFAULT

If Debtor defaults under the proposed payment arrangement or otherwise fails to perform any material obligation under this Statement, Creditor shall have all remedies provided by law and under the original agreement, including but not limited to acceleration of the Outstanding Balance, recovery of costs of collection (including reasonable attorneys' fees), and enforcement of security interests. Creditor's exercise of any remedy shall not preclude exercise of any other remedy.

8. NOTICES

All notices required or permitted under this Statement shall be in writing and delivered to the addresses set forth below by certified mail, overnight courier, or personal delivery. Notices shall be effective upon receipt.

9. GOVERNING LAW

This Statement shall be governed by and construed in accordance with the laws of the state identified by the Creditor Notice Address without regard to conflict of law principles. Venue for any action arising under this Statement shall lie exclusively in the state and federal courts located in the jurisdiction where Creditor's principal place of business is located.

10. ENTIRE AGREEMENT; SEVERABILITY

This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations and agreements, whether written or oral. If any provision of this Statement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

11. AMENDMENTS; WAIVER; COUNTERPARTS

No amendment or waiver of any provision of this Statement shall be effective unless in writing and signed by both parties. The waiver by either party of a breach of any provision shall not operate or be construed as a waiver of any other provision or subsequent breach. This Statement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. CERTIFICATION

Debtor certifies under penalty of perjury that the information provided in this Statement is true and correct to the best of Debtor's knowledge and belief, and acknowledges that Creditor may rely on this certification in evaluating and acting upon the proposed payment arrangement.

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