Promissory Note and Disclosure Statement

Date: _

FOR VALUE RECEIVED, the undersigned jointly and severally
promise to pay to the order of _, the sum of _ ($_) Dollars in
(_) consecutive, monthly payments of $_ 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 of 78’s. 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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