Debt Acknowledgment Form - Template, Sample Form Online

DEBT ACKNOWLEDGMENT AND PROMISE TO PAY

(Acknowledgment of Indebtedness)

This Debt Acknowledgment and Promise to Pay (this “Acknowledgment”) is made and entered into as of ________ (the “Effective Date”), by ________, residing at ________ (the “Debtor”), in favor of ________, residing at ________ (the “Creditor”).

§ 1. Acknowledgment of Indebtedness. The Debtor hereby unconditionally confirms and acknowledges that, as of the Effective Date, the Debtor is justly and truly indebted to the Creditor in the principal sum of $________ (________ Dollars) (the “Indebtedness”).

§ 2. Composition of the Indebtedness. The Indebtedness is owed as of the Effective Date and includes all principal, accrued interest, and other miscellaneous charges permitted by applicable law through the Effective Date. The Indebtedness arises out of ________.

§ 3. Interest. From and after the Effective Date, any unpaid balance of the Indebtedness shall bear interest at the rate of ________% per annum, or the maximum rate permitted by applicable law, whichever is less, computed on the basis of a 365-day year for the actual number of days elapsed.

§ 4. Promise to Pay. The Debtor hereby unconditionally and absolutely promises to pay to the Creditor the entire Indebtedness, together with all accrued interest, on or before ________. Payment shall be made in lawful money of the United States by ________ to the Creditor at the address set forth above or at such other place as the Creditor may designate in writing.

§ 5. No Defenses; No Set-Off. The Debtor acknowledges and agrees that there are no defenses, counterclaims, credits, deductions, or set-offs of any kind whatsoever against the Indebtedness, and the Debtor hereby waives any and all such defenses, counterclaims, credits, deductions, and set-offs as of the Effective Date.

§ 6. Prepayment. The Debtor may prepay all or any portion of the Indebtedness at any time without premium or penalty. Each payment shall be applied first to accrued interest and thereafter to outstanding principal.

§ 7. Default. The occurrence of any of the following shall constitute an event of default: (a) the failure of the Debtor to pay the Indebtedness when due; (b) the Debtor’s insolvency, assignment for the benefit of creditors, or the commencement of any proceeding under the United States Bankruptcy Code by or against the Debtor; or (c) any material breach by the Debtor of any obligation under this Acknowledgment. Upon any event of default, the entire unpaid Indebtedness, together with all accrued interest, shall, at the option of the Creditor, become immediately due and payable without notice or demand.

§ 8. Collection Costs. The Debtor agrees to pay all reasonable costs of collection, including, without limitation, reasonable attorneys’ fees and court costs, incurred by the Creditor in enforcing this Acknowledgment, to the extent permitted by applicable law.

§ 9. Waiver. The Debtor hereby waives presentment for payment, demand, notice of dishonor, protest, and notice of protest, to the extent permitted by applicable law. No delay or omission by the Creditor in exercising any right shall operate as a waiver of such right or any other right.

§ 10. Governing Law. This Acknowledgment shall be governed by and construed in accordance with the laws of the State of ________, without regard to its conflict-of-laws principles. The parties consent to the exclusive jurisdiction and venue of the state and federal courts located in ________ County, State of ________.

§ 11. Severability. If any provision of this Acknowledgment is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect, and the invalid provision shall be deemed modified to the minimum extent necessary to render it valid and enforceable.

§ 12. Entire Agreement; Amendment. This Acknowledgment constitutes the entire understanding of the parties with respect to the Indebtedness and supersedes all prior agreements and understandings. This Acknowledgment may be amended only by a writing signed by both parties.

§ 13. Successors and Assigns. This Acknowledgment shall be binding upon the Debtor and the Debtor’s heirs, executors, administrators, and successors, and shall inure to the benefit of the Creditor and the Creditor’s heirs, executors, administrators, successors, and assigns.

EXECUTION

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore.

Name of Debtor: ________

_____________________________
Signature of Debtor

_____________________________
Date

ACKNOWLEDGMENT

State of ________

County of ________

On this ________ day of ________, 20________, before me, the undersigned notary public, personally appeared ________, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed the same as his/her free act and deed for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year first above written.

Lorem ipsum dolor sit amet consectetur.

Printed Name: ________

My Commission Expires: ________

Notary/Bar Roll Number: ________

Name of Creditor: ________

_____________________________
Signature of Creditor

_____________________________
Date