ACKNOWLEDGEMENT OF DEBT

I, the undersigned, ___________________________________________________________ (the Debtor)

________________________________ (Identity Number) ______________________ (Student Number)

(Postal address) and (Physical/residential address)

____________________________________ ____________________________________

____________________________________ ____________________________________

____________________________________ _____________________________________

do hereby acknowledge that I am truly and lawfully indebted to and on behalf of Sefako Makgatho Health
Sciences University (the Creditor) in the sum of:

__________________________________________________ Rand and_____________ cents (in words).

____________________________________________________________________________ (in figures).

in respect of student and or residence fees from Sefako Makgatho Health Science University.

The University may release my Academic Record but reserve the right to withhold my degree certificate
until such time that payment of the full amount is made or a payment plan is agreed to and honoured.

SIGNED at ____________________________________ on this ______ day of _______________ 2019.

_________________________________________________________________ (Signature, Debtor)

WITNESSES:

1. ___________________________________ (Name) _____________________ (Signature)

2. ___________________________________ (Name) _____________________ (Signature)

Molotlegi Street, Ga-Rankuwa Telephone: +27 12 521 4191

Pretoria, Gauteng Fascimile: +27 86 611 3159
PO Box 60, Medunsa, 0204
www.smu.ac.za