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Payment Account


            BE IT KNOWN, that the undersigned hereby acknowledges receipt of the sum of $                       paid by                                                    which payment constitutes payment on account of the following:


            If this is in partial payment of said obligation the remaining unpaid balance on this date is $                      .

            Signed this    ____   day of                                 , 20    ___   .



________________________                      _________________________

State Specific Receipt Forms

–For State Specific Receipt Forms you can download in Word format, go to


Inside Payment Account