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RECEIPT

BE IT KNOWN, that the undersigned hereby acknowledges receipt of the sum of $_________________ paid by ____________________________________, which payment constitutes ______________ [indicate full or partial] payment of the below described obligation:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

If this is in partial payment of said obligation, the remaining unpaid balance on this date is $_________________.

Signed this ______ day of _____________________, 20______.

Witnessed:

_______________________________
Obligor Signature

_______________________________
Obligor Printed or Typed Name

_______________________________
Witness Signature

_______________________________
Witness Printed or Typed Name

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Receipt

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