DIY Legal Forms

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Assignment Of Receivables

FOR FAIR AND ADEQUATE CONSIDERATION, all rights, title, and interest in all moneys due or that may become due from [Name] as listed on the attached statement of account, is hereby conveyed, transferred, and assigned from [Name], the undersigned, to [Name] hereinafter referred to as the Assignee.


(1) That no payment on the annexed account has been made to the undersigned;

(2) That the entire amount set forth in the annexed account is due and owing; and

(3) No claim, offset, defense, or counterclaim against payment of the attached account exists and that no valid deduction may be made other than that which is set out in the annexed account, if any.

Signed under seal on [Date].



This Section for Notary:


STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.


[Name of Notary Public]

My commission expires: [date]