RECEIPT

(SPECIFIC)

This receipt acknowledges full payment, and unconditional release of the following items:

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

We ______________________________________ (Name of Payee) acknowledge the receipt/payment of ___________________________ (Amount) ($_________) from _______________________ (Name of Payer) fulfilling all of the terms of the original agreement dated _______________________ (Date).

_____________________________ Date: ________________________

Signed

_____________________________ Date: ________________________

Signed

_____________________________ Date: ________________________

Witness