Full names:______________(lender)
Address:_______________

Full names:______________(Borrower)
Address:_______________

Re: promissory Note dated___________20___
The Lender hereby acknowledges receipt of the sum of_____________
As payment in respect of the note referenced above.
As per terms of the Note all payments shall first be applied to interest accrued to date and thereafter to the principal amount. The remaining unpaid balance on this date is______
Signed on this ______ day of _____ 20__
Signature of Lender:
Signature of Witness:

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