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                            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:

_______________________________
Witness _______________________________
Obligor

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* Notice of Default in Payment

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