Debt Acknowledgement

The undersigned hereby acknowledges that the present balance owing to ___________________ (the "Company") by the undersigned is in the amount of $___________________ including all accrued interest and other charges to date.

The undersigned further acknowledges that there are no credits, equities or setoffs against this agreed account balance.

Dated this________ day of__________________, 201(x) .

 

______________________________________
Customer

 

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