Fill and Sign the Disputed Accounted Settlement Form

Disputed Accounted Settlement Settlement Agreement made on the _________________ (date) , between _______________________ (Name of Debtor) , a corporation organized and existing under the laws of the state of __________________, with its principal office located at ______________________________________________________________________ (street address, city, state, zip code) , referred to herein as Debtor , and _________________________ (Name of Creditor) , a corporation organized and existing under the laws of the state of _________________, with its principal office located at _____________________________________________________________ ______________ (street address, city, state, zip code) , referred to herein as Creditor . Whereas, Creditor asserts to hold certain claim against Debtor in the amount of $______________ arising from the below described transaction: (describe) ______________________________________________________________________ __________________________________________________________________; and Whereas, Debtor disputes said claim, and denies said debt is due; and Whereas, the parties desire to resolve and forever settle and adjust said claim. Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1 Debtor agrees to pay to Creditor and Creditor agrees to accept from Debtor simultaneous herewith, the sum of $__________ in full payment, settlement, satisfaction, discharge and release of said claim and in release of any further claims thereto. Creditor acknowledges that there shall be no adverse report filed against Debtor with any credit bureau. 2. This Agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns and personal representatives. WITNESS our signatures as of the day and date first above stated. _______________________ ______________________ (Name of Debtor) (Name of Creditor) By:____________________________ By:___________________________ __________________________ _________________________ (P rinted Name & Office in Corporation) (P rinted Name & Office in Corporation) __________________________ ___________________________ (Signature of Officer) (Signature of Officer) (Acknowledgment form may vary by state) STATE OF _____________ COUNTY OF ____________ Personally appeared before me, the undersigned authority in and for the said county and state, on this _____ day of ____________, 20____, within my jurisdiction, the within named _________________ (Name of Officer) , who acknowledged that he is _________________ (Name of Office) of ______________________ (Name of Corporation) , a ________________ (name of state) corporation, and that for and on behalf of the said corporation, and as its act and deed he executed the above and foregoing instrument, after first having been duly authorized by said corporation so to do. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________ STATE OF _____________ COUNTY OF ____________ Personally appeared before me, the undersigned authority in and for the said county and state, on this ______ day of ____________, 20_____, within my jurisdiction, the within named ___________________ (Name of Officer) , who acknowledged that he is _________________ (Name of Office) of _____________________ (Name of Corporation) , a _________________ (name of state) corporation, and that for and on behalf of the said corporation, and as its act and deed he executed the above and foregoing instrument, after first having been duly authorized by said corporation so to do. ________________________________ NOTARY PUBLIC My Commission Expires: ____________________