How to prepare legal forms (click here)

Acknowledgment Of Receipt Of Collateral

1. Acknowledgment of Receipt of Collateral. I, [name] (Creditor), acknowledge receipt of [number] shares of the common stock of [name] from [name] (Debtor), in accordance with the terms of a note executed by Debtor to my order on [date] in the sum of ---------- dollars ($----------). I also acknowledge receipt of [number] stock powers signed in blank by Debtor.

2. Creditor to Safeguard Collateral. While the collateral is in my possession, I will keep it in a secure place, reasonably protected from loss by casualty or theft.

3. Return of Collateral to Debtor. Upon payment by Debtor of all sums due on the note, I will promptly return all collateral and all stock powers signed in blank by Debtor held by me, unless the collateral has been sold in accordance with the note's provisions.

[dated]

[signature]

Creditor