We, __________________, ___________________, and _____________________ as Tenants in _____________ (the "Customer"), being first duly sworn, hereby depose and say that:
We have entered into a $________ loan transaction with ________ Bank and Trust Company, ___________, _______________ (the "Creditor") on ________, 20__ which may result in a lien, mortgage, or other security interest on our home.
We hereby waive our right to rescind the transaction for the following reasons:
The extension of credit is vitally necessary to meet a bonafide personal financial emergency, whereby a delay of three (3) business days in performance of Creditor's obligation under this transaction will jeopardize our financial welfare and endanger us and our family.
Therefore, We hereby waive our right of rescission and do so under the pains and penalties of perjury this _______day of _______, 20__.
Signatures witnessed by: