Disclosure Statement and Note

(Federal Truth-in-Lending Act)

Date:

Amount:

FOR VALUE RECEIVED, the borrower ______________________, residing at _____________________, shall pay to the order of _______________________, the total amount of ________________________ dollars ($------) in consecutive payments payable on the _______ day of the month __________, beginning on _________, 20 ____, until the loan is paid in full.

Failure to make a payment when due shall be a default of the loan. Should a default exist for more than (--) days, the holder of this note may cause the entire loan to be due immediately.

1. Amount of Loan:

2. Expenses:

3. Total Financed:

4. Interest Charges:

5. Total of Payments:

6. Annual Financed Percentage Rate:

Signed: ______________________
Borrower

*** If Required By State Law ***

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)