For value received, the undersigned (jointly and severally, if more than one) promises to pay to _________ ____________ the principal sum of _______________ (amount) with interest from date at the rate of ______ ( rate) percent per annum on the balance from time to time remaining unpaid. The said principal and interest shall be payable in lawful money of the _______________ (country) at________________ (city) or at such place as may hereafter be designated by written notice from the holder to the maker hereof, on the date and in the manner following:

Upon demand after ______________________________

Maker’s Address _____________________________ (SEAL)

_____________________________ (SEAL)

_____________________________ (SEAL)