Receipt

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