Payment Account

RECEIPT 

            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    ___   .

                                                           ________________________________

Witnessed:

________________________                      _________________________

State Specific Receipt Forms

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

http://secure.uslegalforms.com/cgi-bin/forms/query.pl?S-T-B-B-receipt


Inside Payment Account