DIY Legal Forms

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Acknowledgment of Receipt of Collateral

1. Acknowledgment of Receipt of Collateral. I, [name] (Creditor), acknowledge receipt of [number] shares of the common stock of [name] from [name] (Debtor), in accordance with the terms of a note executed by Debtor to my order on [date] in the sum of ---------- dollars ($----------). I also acknowledge receipt of [number] stock powers signed in blank by Debtor.

2. Creditor to Safeguard Collateral. While the collateral is in my possession, I will keep it in a secure place, reasonably protected from loss by casualty or theft.

3. Return of Collateral to Debtor. Upon payment by Debtor of all sums due on the note, I will promptly return all collateral and all stock powers signed in blank by Debtor held by me, unless the collateral has been sold in accordance with the note's provisions.

[dated]

[signature]

Creditor

STATE OF ----------)

) s.s.:

COUNTY OF ---------)

On this [date] before me came [name], to me known and known to me to be the individual described in and who executed the foregoing instrument, and he acknowledged that he executed the same.

[signature]

Notary Public

Witness my hand and official seal.

Signature ________________________
Notary

My commission expires: _____

(Seal)