Fill and Sign the Disclosures Required Form

GENERAL DISCLOSURES REQUIRED BY THE FEDERAL TRUTH IN LENDING ACT Retail Installment Contract – Closed End Disclosures Seller's Name: ______________________ (name of seller) Seller's Business Address: ____________________________________________________ _____________________________________________________ (address of seller) Buyer's Name: ______________________ (name of buyer) Buyer's Address: _____________________________________________________________ ______________________________________________________ (address of buyer) 1. Amount Financed (the amount of credit provided to you or on your behalf) $___________ 2. FINANCE CHARGE (the dollar amount the credit will cost you) $___________ 3. ANNUAL PERCENTAGE RATE (the cost of your credit as a yearly rate) ______% 4. Total of Payments (the amount you will have paid after you have made all payments as scheduled) $___________ 5. Total Sales Price (the total price of your purchase on credit, including your down payment of (dollar amount) $___________ 6. Itemization of Amount Financed. You have a right to receive a written itemization of the Amount Financed. If you DO want a written itemization of the Amount Financed, you will receive one only if you check the "Yes" box immediately below. If you check the "No" box or do not check either box, you will not receive a written itemization. [ ] Yes [ ] No 7. Payment Schedule. Your payment schedule will be: Number of Payments Payment Amount When Payments are Due __________ $ _____________ ____________________ (number) (date) __________ $ _____________ ____________________ (number) (date) __________ $ _____________ ____________________ (number) (date) 8. Insurance. Credit life insurance and credit disability insurance are not required to obtain credit, and will not be provided unless you sign in the space(s) immediately below and agree to pay the additional cost indicated. Type of Insurance Premium Signature Credit Life $___________ I want credit life insurance. _______________________ (Signature) Credit Disability $___________ I want credit disability insurance. _______________________ (Signature) Credit Life & Disability $___________ I want credit life & disability insurance. ________________________ (Signature) You may obtain property insurance from anyone you want that is acceptable to seller/creditor or its assignee. If you get the insurance from seller/creditor, you will pay $___________for ______ (number) months' coverage. 9. Security Interest. You are giving a security interest in [ ] the goods or property being purchased [ ] other (brief description of other property) _______________________________ ______________________________________________________________________ 10. (a) Filing fees $__________ (b) Non-filing Insurance $__________ 11. Late Charge. If a payment is late, you will pay (check one) [ ] $____________. [ ] ____ % of the payment amount. [ ] $____________ or ____ % of the payment amount, whichever is ____________ (larger/smaller) . 12. Prepayment. If you pay off early, you may be entitled to a refund of part of the Finance Charge, and (check one) [ ] may have to pay a penalty. [ ] will not have to pay a penalty. See your contract documents for any additional information about nonpayment, default, any required repayment in full before the maturity date, and prepayment refunds and penalties. _______________ "e" means estimate ________________ ANY HOLDER OF THIS CONSUMER CREDIT CONTRACT IS SUBJECT TO ALL CLAIMS AND DEFENSES WHICH THE DEBTOR COULD ASSERT AGAINST THE SELLER OF GOODS OR SERVICES OBTAINED PURSUANT HERETO OR WITH THE PROCEEDS HEREOF. RECOVERY HEREUNDER BY THE DEBTOR SHALL NOT EXCEED AMOUNTS PAID BY THE DEBTOR HEREUNDER.