DIY Legal Forms

“Help us to stay online by your kind donation.

Every penny will help.”


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.




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.


Notary Public

Witness my hand and official seal.

Signature ________________________

My commission expires: _____