ACKNOWLEDGMENT OF DEBT

I, ________________________ (Debtor), of legal age, _____________,

single/married, and a resident of ____________________________________, after
being duly sworn to in accordance with law, witnesseth and declare:

That I am indebted in the sum of _________________________(amount).

(_________), _________ Currency, to _____________________________
(Creditor), who is also of legal age, single/married, and a
resident of ________________________________________.

I hereby bind myself to pay the full amount of the said capital not later than
________________________ (Final Date of Repayment) from today, with interest at the
rate of _____ Percent (___%) per centum per month until fully paid.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of

___________________ in ______________________________.

___________________________
Debtor

SIGNED IN THE PRESENCE OF:

__________________________
Witness