I hereby acknowledgement that a sum of Rs………………………./-

(Rupees in word…………………………………………………………………………………………..)

Is due from me to Shri/ Mr/ Mrs/Miss…………………………………………………………………….

S/o……………………………………………………………………………………………………………

R/o……………………………………………………………………………………………………………

S/d……………………………………………………….

S/o. Shri…………………………………………………

Date:…………………. Address:………………………………………………..

…………………………………………………………..

…………………………………………………………..

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