Acknowledgement of

Payment Receipt

Receipt #

________________________________

Date:

________________________________

Total Amount of Money

________________________________

Type of Payment

[ ] Cash

[ ] Check - No. _____

[ ] Money Order - No. _____

Money to be Used For

____ ______________________________________________________

____ ______________________________________________________

Terms and Conditions

___________________________________________________________

___________________________________________________________
Repayment Agreement

___________________________________________________________

___________________________________________________________

Money Received by

________________________________

Name

_______________________ Date_____

Money Provided by

________________________________

Name

_______________________ Date_____