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Disclosure Statement & Note

(Type B)

Federal Truth-in-Lending Act

Date:

FOR VALUE RECEIVED, the undersigned jointly and severally promise to pay to the order of, the sum of [$-------] in consecutive, monthly payments of [$-------] each, beginning one month from date hereof and thereafter on the same date of each subsequent month until paid in full. Any unpaid balance may be paid at any time without penalty and any unearned finance charges will be refunded. In the event that undersigned defaults in any payment beyond [--] days from the due date, the entire balance may be due at the option of any holder.

1. Proceeds [$-------].

2. Other charges (itemize) [$-------].

3. Amount financed [$-------].

4. Total of payments [$-------].

5. Annual Percentage Rate [--%] percent.

Signature

[Name], Undersigned

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

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.

Signature ________
Notary

My commission expires: _____

(Seal)