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Promissory note and disclosure statement [Federal Truth in Lending Act]

Date: ____________

For value received, the undersigned jointly and severally promise to pay to the order of ___________________, the sum of _____________(amounts)in ________ consecutive, monthly payments of _____________ (amounts) each, beginning one month from date hereof and thereafter on the same date of each subsequent month until paid in full. Any unpaid balance may be paid at any time without penalty and any unearned finance charges will be refunded based on the______________ (rule). In the event the undersigned defaults in any payment beyond ____________ days from the due date, the entire balance may be due at the option of the holder.

1. Proceeds ________________________________________

2. Other charges [itemize] ___________________________

3. Amount financed [1+2] ___________________________

4. Total of payments ________________________________

5. Annual Percentage Rate _______________ %



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