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I, _________________________, hereby acknowledge the receipt of

____________________________, the purchase price of which amounts to ________________,
on _____________________. I understand that I will be accountable for any future loss or
damage which will occur on the thing/s that I have received. I further agree to pay any cost that
will be incurred for the replacement or repair of the above-mentioned thing in case of loss or
damage provided that the occurrence of the loss or damage is caused by my negligence or
intentional destruction. Damage or loss occurred without overt acts or negligence on my part,
(e.g. damage due to the thing’s long existence or system default) shall be justified.

Received by:

________________________ _______________
Signature Over Printed Name Date


_________________________ _____________________