Declaration

I _______________________________________________________, aged ___________,

NUIT: ________________, declare that I received the amount of ____________________ MTS
on the date of ________/________/________ that I will pay on _____________/
____________/___________ with the interest of 30% which corresponds to
__________________MTS. As to prove that this declaration is authentic, the creditor and I will
sigh this declaration and a copy of the respective ID and NUIT is attached.

Beneficiary Creditor

_____________________________ ___________________________