TERM LINE NOTE Maryland
M&T
BANK
Manufacturers
and Traders Trust Company
|
July
__, 2006
|
$1,300,000.00
|
BORROWER:
Payments,
Inc., a New York corporation
and
DCAP
Group, Inc., a Delaware corporation
with
its primary place of business located at:
0000
Xxxxxxxx
Hewlett,
New York 11557
Attention: Xxxxx
X.
Xxxxxxxxx
|
BANK:
|
MANUFACTURERS
AND TRADERS TRUST COMPANY, a New York banking corporation with its
banking
offices at Xxx X&X Xxxxx, Xxxxxxx, XX 00000 Attention: Office of the
General Counsel.
|
Promise
to Pay.
For
value received, intending to be legally bound, Borrower promises to pay to
the
order of the Bank, on the dates set forth below, the principal sum of One
Million Three Hundred Thousand Dollars ($1,300,000.00) (the “Principal”) plus
interest as agreed below and all fees and costs (including without limitation
attorneys’ fees and disbursements whether for internal or outside counsel) the
Bank incurs in order to collect any amount due under this Note, to negotiate
or
document a workout or restructuring, or to preserve its rights or realize upon
any guaranty or other security for the payment of this Note
(“Expenses”).
Financing
Agreement; Financing Documents. This
Note
is the “Term Line Note” described in an Amended and Restated Financing and
Security Agreement of even date herewith by and between the Borrower and the
Lender (as amended, modified, restated, substituted, extended and renewed at
any
time and from time to time, the “Financing Agreement”). The indebtedness
evidenced by this Note is included within the meaning of the term “Obligations”
as defined in the Financing Agreement. This Note is one of the “Financing
Documents” (as that term is defined in the Financing Agreement). All capitalized
terms used herein and not otherwise defined shall have the meaning set forth
in
the Financing Agreement.
Interest.
The
unpaid Principal of this Note shall earn interest calculated on the basis of
a
360-day year for the actual number of days of each year (365 or 366), from
and
including the date the proceeds of this Note are disbursed to, but not
including, the date all amounts hereunder are paid in full, at a rate per year
as set forth in Section 2.4.1 (Applicable Interest Rate -Term Line) of the
Financing Agreement.
Maximum
Legal Rate.
It is
the intent of the Bank and Borrower that in no event shall interest be payable
at a rate in excess of the maximum rate permitted by applicable law (the
“Maximum Legal Rate”). Solely to the extent necessary to prevent interest under
this Note from exceeding the Maximum Legal Rate, Xxxxxxxx agrees that any amount
that would be treated as excessive under a final judicial interpretation of
applicable law shall be deemed to have been a mistake and automatically
canceled, and, if received by the Bank, shall be refunded to Borrower, without
interest.
Default
Rate.
If an
Event of Default (defined below) occurs, the interest rate on the unpaid
Principal shall immediately be automatically increased to the Post-Default
Rate
as set forth in the Financing Agreement.
Repayment
of Principal and Interest; Late Charge.
Payments
shall be made in immediately available United States funds at any banking office
of the Bank. Interest will continue to accrue until payment is actually
received. Payments may be applied in any order in the sole discretion of the
Bank but, prior to default, shall be applied first to past due interest,
Expenses, late charges and principal, then to current interest, Expenses, late
charges and principal, and last to remaining principal.
The
Maturity Date of this Note is the Term Line Maturity Date (as defined in the
Financing Agreement).
o Borrower
shall pay the entire Principal on the Maturity Date. In addition, until the
outstanding Principal is paid in full, payments of all accrued and unpaid
interest in amounts which will vary will become due and payable on the
_________________ day of each:
o
month
o
quarter
o
year
commencing on _________________________, 20____.
x Borrower
shall pay the Principal in o
monthly
x
quarterly o
annual
installments commencing on September 1, 2006 and on the first day of each
o
month
x
quarter
o
year
thereafter consisting of equal installments each in the amount of $130,000.00
and ONE (1) FINAL INSTALLMENT on the Maturity Date in an amount equal to the
outstanding Principal together with all other amounts outstanding hereunder
including, without limitation, accrued interest, costs and expenses. In
addition, until the outstanding Principal is paid in full, payments of all
accrued and unpaid interest in amounts which will vary will become due and
payable on the first day of each: x
month
o
quarter
o
year
commencing on August 1, 2006.
o Borrower
shall pay Principal and interest in __________________ consecutive level
o
monthly
o
quarterly o
annual
installments consisting of both Principal and interest, amortized over a period
of________ years, commencing on _________________________, 20____
and on
the ________________ day of each o
month
o
quarter
o
year
thereafter consisting of ______________ equal installments of Principal and
interest each in the amount of $_______________________and ONE (1) FINAL
INSTALLMENT on the Maturity Date in an amount equal to the outstanding Principal
together with all other amounts outstanding hereunder including, without
limitation, accrued interest,
1
costs
and
expenses.
PLEASE NOTE: The
Final
Installment may be higher than expected if any payment is received after its
due
date. Furthermore, to the extent that (i) the repayment terms of this Note
contemplate level installments of Principal and interest during any period
in
which the applicable interest rate is a variable rate (“Variable Rate P&I
Period”), and (ii) during any such Variable Rate P&I Period, the applicable
interest rate changes in accordance with the terms of this Note, the following
provisions shall apply: (a) if the amount of accrued interest during any
installment period shall exceed the amount of Borrower’s scheduled installment
of Principal and interest for that period, the amount of the installment due
and
payable to the Bank for that period shall be adjusted (i.e., increased) to
equal
the amount of interest accrued for that period, so as to avoid negative
amortization; and (b) in all other instances of applicable interest rate
fluctuation during a Variable Rate P&I Period, Xxxxxxxx’s scheduled
installment of Principal and interest will remain the same and, in such
instances where the applicable interest rate increases, result in a greater
portion of such installment amount being applied to interest due, leaving less
available to reduce the Principal balance. Borrower understands that each
scenario will result in a higher than expected Principal balance due and payable
to the Bank on the Maturity Date, and agrees that, absent manifest error, the
Bank’s determination of any amount due in connection herewith shall be
conclusive.
Prepayment
Premium.
During
the term of this Note, Borrower shall have the option of paying the unpaid
Principal to the Bank in advance of the Maturity Date, as set forth in Section
2.2.6 (Optional Prepayments of Term Line) of the Financing Agreement.
Representations,
Warranties and Covenants. Borrower
represents, warrants and acknowledges to, and agrees and covenants with, the
Bank that now and until this Note is paid in full:
a. Business
Purpose.
This
Note evidences a commercial loan and an extension of credit for a commercial
purpose within the meaning of the Commercial Law Article of the Annotated Code
of Maryland, and the loan proceeds shall be used only for a business purpose
and
not for any personal, family or household purpose.
b. Good
Standing; Authority.
Borrower
is an entity (i) duly organized and existing and in good standing under the
laws
of the jurisdiction in which it was formed, (ii) duly qualified, in good
standing and authorized to do business in every jurisdiction in which failure
to
be so qualified might have a material adverse effect on its business or assets
and (iii) has the power and authority to own each of its assets and to use
them
as contemplated now or in the future.
c. Legality.
The
execution, issuance, delivery to the Bank and performance by Borrower of this
Note (i) are in furtherance of Borrower’s purposes and within its power and
authority; (ii) do not (a) violate any statute, regulation or other law or
any
judgment, order or award of any court, agency or other governmental authority
or
of any arbitrator or (b) violate Borrower’s certificate of incorporation or
other governing instrument, constitute a default under any agreement binding
on
Borrower, or result in a lien or encumbrance on any assets of Borrower; and
(iii) have been duly authorized by all necessary corporate or partnership
action.
d. Compliance.
The
Borrower conducts its business and operations and the ownership of its assets
in
compliance with each applicable statute, regulation and other law, including
without limitation environmental laws. All approvals, including without
limitation authorizations, permits, consents, franchises, licenses,
registrations, filings, declarations, reports and notices (the “Approvals”)
necessary to the conduct of Xxxxxxxx’s business and for Xxxxxxxx’s due issuance
of this Note have been duly obtained and are in full force and effect. The
Borrower is in compliance with all conditions of each Approval.
e. Financial
and Other Information.
For each
year until this Note is paid in full, Borrower shall provide to the Bank in
form
and number of copies and by accountants satisfactory to the Bank, such financial
information as required by the Financing Agreement.
f. Accounting;
Tax Returns and Payment of Claims.
Borrower
will maintain a system of accounting and reserves in accordance with generally
accepted accounting principles, has filed and will file each tax return required
of it and, except as disclosed in an attached schedule, has paid and will pay
when due each tax, assessment, fee, charge, fine and penalty imposed by any
taxing authority upon Borrower or any of its assets, income or franchises,
as
well as all amounts owed to mechanics, materialmen, landlords, suppliers and
the
like in the ordinary course of business.
g. Title
to Assets; Insurance.
Borrower
has good and marketable title to each of its assets free of security interests
and mortgages and other liens except as disclosed in its financial statements
or
on a schedule attached to this Note or pursuant to the Bank’s prior written
consent. Borrower will maintain its property in good repair and will maintain
and on request provide the Bank with evidence of insurance coverage satisfactory
to the Bank including without limitation fire and hazard, liability, worker’s
compensation and business interruption insurance and flood hazard insurance
as
required.
h. Judgments
and Litigation.
There is
no pending or threatened claim, audit, investigation, action or other legal
proceeding or judgment, order or award of any court, agency or other
governmental authority or arbitrator (each an “Action”) which involves Borrower
or its assets and might have a material adverse effect upon Borrower or threaten
the validity of this Note or any related document or transaction. Xxxxxxxx
will
immediately notify the Bank in writing upon acquiring knowledge of any such
Action.
i. Notice
of Change of Address and of Default.
Borrower
will immediately notify the Bank in writing (i) of any change in its address
or
of the location of any collateral securing this Note, (ii) of the occurrence
of
any Event of Default defined below, (iii) of any material change in Borrower’s
ownership or management and (iv) of any material adverse change in Borrower’s
ability to repay this Note.
j. No
Transfer of Assets.
Until
this Note is paid in full, Borrower shall not without the prior written consent
of the Bank (i) sell or otherwise dispose of substantially all of its assets,
(ii) acquire substantially all of the assets of another entity, (iii) if it
is a
corporation, participate in any merger, consolidation or other absorption or
(iv) agree to do any of these things.
Events
of Default.
The
following constitute an event of default (“Event of Default”): (i) failure by
Borrower to make any payment when due (whether at the stated maturity, by
acceleration or otherwise) of the amounts due under this Note, the Financing
Agreement or the other Financing
2
Documents,
or any part thereof, or there occurs any event or condition which after notice,
lapse of time or both will permit such acceleration; (ii) Borrower defaults
in
the performance of any covenant or other provision with respect to this Note,
the Financing Agreement, or any other agreement between Borrower and the Bank
or
any of its affiliates or subsidiaries (collectively, “Affiliates”); (iii)
Borrower fails to pay when due (whether at the stated maturity, by acceleration
or otherwise) any indebtedness for borrowed money owing to the Bank (other
than
under this Note), any third party or Affiliate or the occurrence of any event
which could result in acceleration of payment of any such indebtedness or the
failure to perform any agreement with any third party or Affiliate; (iv) the
reorganization, merger, consolidation or dissolution of Borrower (or the making
of any agreement therefor); the sale, assignment, transfer or delivery of all
or
substantially all of the assets of Borrower to a third party; or the cessation
by Xxxxxxxx as a going business concern; (v) the death or judicial declaration
of incompetency of Borrower, if an individual; (vi) failure to pay, withhold
or
collect any tax as required by law; the service or filing against Borrower
or
any of its assets of any lien (other than a lien permitted in writing by the
Bank), judgment, garnishment, order or award; (vii) if Borrower becomes
insolvent or is generally not paying its debts as such debts become due; (viii)
the making of any general assignment by Borrower for the benefit of creditors;
the appointment of a receiver or similar trustee for Borrower or its assets;
or
the making of any, or sending notice of any intended, bulk sale; (ix) Borrower
commences, or has commenced against it, any proceeding or request for relief
under any bankruptcy, insolvency or similar laws now or hereafter in effect
in
the United States of America or any state or territory thereof or any foreign
jurisdiction or any formal or informal pro-ceeding for the dissolution or
liquidation of, settlement of claims against or winding up of affairs of
Borrower; (x) any representation or warranty made in this Note, the Financing
Agreement, any related document, any agreement between Borrower and the Bank
or
any Affiliate or in any financial statement of Borrower proves to have been
misleading in any material respect when made; Borrower omits to state a material
fact necessary to make the statements made in this Note, the Financing
Agreement, any related document, any agreement between Borrower and the Bank
or
any Affiliate or any financial statement of Borrower not misleading in light
of
the circumstances in which they were made; or, if upon the date of execution
of
this Note, there shall have been any material adverse change in any of the
facts
disclosed in any financial statement, representation or warranty that was not
disclosed in writing to the Bank at or prior to the time of execution hereof;
(xi) any pension plan of Borrower fails to comply with applicable law or has
vested unfunded liabilities that, in the opinion of the Bank, might have a
material adverse effect on Borrower’s ability to repay its debts; (xii) an
adverse change in the Borrower, its business, assets, operations, management,
ownership, affairs or condition (financial or otherwise) from the status shown
on any financial statement or other document submitted to the Bank or any
Affiliate, and which change the Bank determines will have a material adverse
effect on (a) the Borrower, its business, assets, operations or condition
(financial or otherwise), or (b) the ability of the Borrower to pay or perform
any obligation to the Bank; (xiii) the occurrence of any event described in
sub-paragraph (i) through and including (xii) hereof with respect to any
guarantor or any other party liable for, or whose assets or any interest therein
secures, payment of any of the amounts due under this Note; (xiv) Borrower
fails
to supply new or additional collateral within ten (10) days of request by the
Bank; or (xv) the Bank in good xxxxx xxxxx itself insecure with respect to
payment or performance under this Note, the Financing Agreement or any of the
other Financing Documents.
Rights
and Remedies Upon Default.
Upon the
occurrence of any Event of Default, the Bank without demand of performance
or
other demand, presentment, protest, advertisement or notice of any kind (except
any notice required by law) to or upon the Borrower or any other person (all
and
each of which demands, presentments, protests, advertisements and notices are
hereby waived), may exercise all rights and remedies under the Borrower’s
agreements with the Bank or its Affiliates, applicable law, in equity or
otherwise and may declare all or any part of any amounts due hereunder not
payable on demand to be immediately due and payable without demand or notice
of
any kind and terminate any obligation it may have to grant any additional loan,
credit or other financial accommodation to the Borrower. All or any part of
any
amounts due hereunder whether or not payable on demand, shall be immediately
due
and payable automatically upon the occurrence of an Event of Default in
sub-paragraph (ix) above, or at the Bank’s option, upon the occurrence of any
other Event of Default. The provisions hereof are not intended in any way to
affect any rights of the Bank with respect to any amounts due hereunder which
may now or hereafter be payable on demand.
Right
of Setoff.
The Bank
shall have the right to set off against the amounts owing under this Note any
property held in a deposit or other account with the Bank or any Affiliates
or
otherwise owing by the Bank or any Affiliate in any capacity to Borrower or
any
Guarantor or endorser of this Note. Such setoff shall be deemed to have been
exercised immediately at the time the Bank or such Affiliate elects to do
so.
Miscellaneous.
This
Note, together with any related loan and security agreements and guaranties,
contains the entire agreement between the Bank and Borrower with respect to
the
Note, and supersedes every course of dealing, other conduct, oral agreement
and
representation previously made by the Bank. All rights and remedies of the
Bank
under applicable law and this Note or amendment of any provision of this Note
are cumulative and not exclusive. No single, partial or delayed exercise by
the
Bank of any right or remedy shall preclude the subsequent exercise by the Bank
at any time of any right or remedy of the Bank without notice. No waiver or
amendment of any provision of this Note shall be effective unless made
specifically in writing by the Bank. No course of dealing or other conduct,
no
oral agreement or representation made by the Bank, and no usage of trade, shall
operate as a waiver of any right or remedy of the Bank. No waiver of any right
or remedy of the Bank shall be effective unless made specifically in writing
by
the Bank. Xxxxxxxx agrees that in any legal proceeding, a copy of this Note
kept
in the Bank’s course of business may be admitted into evidence as an original.
This Note is a binding obligation enforceable against Borrower and its
successors and assigns and shall inure to the benefit of the Bank and its
successors and assigns. If a court deems any provision of this Note invalid,
the
remainder of the Note shall remain in effect. Section headings are for
convenience only. Singular number includes plural and neuter gender includes
masculine and feminine as appropriate.
Notices.
Any
demand or notice hereunder or under any applicable law pertaining hereto shall
be in writing and duly given if delivered to Borrower (at its address on the
Bank’s records) or to the Bank (at the address on page one and separately to the
Bank officer responsible for Xxxxxxxx’s relationship with the Bank). Such notice
or demand shall be deemed sufficiently given for all purposes when delivered
(i)
by personal delivery and shall be deemed effective when delivered, or (ii)
by
mail or courier and shall be deemed effective three (3) business days after
deposit in an official depository maintained by the United States Post Office
for the collection of mail or one (1) business day after delivery to a
nationally recognized overnight courier service (e.g.,
Federal
Express). Notice by e-mail is not valid notice under this or any other agreement
between Borrower and the Bank.
Joint
and Several.
If there
is more than one Borrower, each of them shall be jointly and severally liable
for all amounts and obligations which become due under this Note and the term
“Borrower” shall include each as well as all of them.
3
Governing
Law; Jurisdiction.
This
Note has been delivered to and accepted by the Bank and will be deemed to be
made in the State of Maryland. Except as otherwise provided under federal law,
this Note will be interpreted in accordance with the laws of the State of
Maryland excluding its conflict of laws rules. BORROWER
HEREBY IRREVOCABLY CONSENTS TO THE EXCLUSIVE JURISDICTION OF ANY STATE OR
FEDERAL COURT IN THE STATE OF MARYLAND WHERE THE BANK MAINTAINS A BRANCH AND
CONSENTS THAT THE BANK MAY EFFECT ANY SERVICE OF PROCESS IN THE MANNER AND
AT
BORROWER’S ADDRESS SET FORTH ABOVE FOR PROVIDING NOTICE OR DEMAND; PROVIDED THAT
NOTHING CONTAINED IN THIS NOTE WILL PREVENT THE BANK FROM BRINGING ANY ACTION,
ENFORCING ANY AWARD OR JUDGMENT OR EXERCISING ANY RIGHTS AGAINST BORROWER
INDIVIDUALLY, AGAINST ANY SECURITY OR AGAINST ANY PROPERTY OF BORROWER WITHIN
ANY OTHER COUNTY, STATE OR OTHER FOREIGN OR DOMESTIC
JURISDICTION.
Borrower
acknowledges and agrees that the venue provided above is the most convenient
forum for both the Bank and Borrower. Borrower waives any objection to venue
and
any objection based on a more convenient forum in any action instituted under
this Note.
Waiver
of Jury Trial. XXXXXXXX AND THE BANK HEREBY KNOWINGLY, VOLUNTARILY AND
INTENTIONALLY WAIVE ANY RIGHT TO TRIAL BY JURY BORROWER AND THE BANK MAY HAVE
IN
ANY ACTION OR PROCEEDING, IN LAW OR IN EQUITY, IN CONNECTION WITH THIS NOTE
OR
THE TRANSACTIONS RELATED HERETO. XXXXXXXX REPRESENTS AND WARRANTS THAT NO
REPRESENTATIVE OR AGENT OF THE BANK HAS REPRESENTED, EXPRESSLY OR OTHERWISE,
THAT THE BANK WILL NOT, IN THE EVENT OF LITIGATION, SEEK TO ENFORCE THIS JURY
TRIAL WAIVER. XXXXXXXX ACKNOWLEDGES THAT THE BANK HAS BEEN INDUCED TO ENTER
INTO
THIS NOTE BY, AMONG OTHER THINGS, THE PROVISIONS OF THIS
SECTION.
Power
to Confess Judgment. XXXXXXXX XXXXXX EMPOWERS ANY ATTORNEY OF ANY COURT OF
RECORD, AFTER THE OCCURRENCE OF ANY EVENT OF DEFAULT HEREUNDER, TO APPEAR FOR
BORROWER AND, WITH OR WITHOUT COMPLAINT FILED, CONFESS JUDGMENT, OR A SERIES
OF
JUDGMENTS, AGAINST XXXXXXXX IN FAVOR OF THE BANK OR ANY HOLDER HEREOF FOR THE
ENTIRE PRINCIPAL BALANCE OF THIS NOTE, ALL ACCRUED INTEREST AND ALL OTHER
AMOUNTS DUE HEREUNDER, TOGETHER WITH COSTS OF SUIT AND AN ATTORNEY’S COMMISSION
OF THE GREATER OF TEN PERCENT (10%) OF SUCH PRINCIPAL AND INTEREST OR $1,000
ADDED AS A REASONABLE ATTORNEY’S FEE, AND FOR DOING SO THIS NOTE OR A COPY
VERIFIED BY AFFIDAVIT SHALL BE A SUFFICIENT WARRANT. BORROWER HEREBY FOREVER
WAIVES AND RELEASES ALL ERRORS IN SAID PROCEEDINGS AND ALL RIGHTS OF APPEAL
AND
ALL RELIEF FROM ANY AND ALL APPRAISEMENT, STAY OR EXEMPTION LAWS OF ANY STATE
NOW IN FORCE OR HEREAFTER ENACTED. INTEREST ON ANY SUCH JUDGMENT SHALL ACCRUE
AT
THE DEFAULT RATE. NO SINGLE EXERCISE OF THE FOREGOING POWER TO CONFESS JUDGMENT,
OR A SERIES OF JUDGMENTS, SHALL BE DEEMED TO EXHAUST THE POWER, WHETHER OR
NOT
ANY SUCH EXERCISE SHALL BE HELD BY ANY COURT TO BE INVALID, VOIDABLE, OR VOID,
BUT THE POWER SHALL CONTINUE UNDIMINISHED AND IT MAY BE EXERCISED FROM TIME
TO
TIME AS OFTEN AS THE BANK SHALL ELECT UNTIL SUCH TIME AS THE BANK SHALL HAVE
RECEIVED PAYMENT IN FULL OF THE DEBT, INTEREST AND COSTS. THE
PROVISIONS OF THIS SECTION DO NOT APPLY TO ANY LOAN EVIDENCED BY THIS NOTE
THAT
IS WITHIN THE SCOPE OF THE SECTION ENTITLED “SPECIAL PROVISIONS - LOANS OF
$75,000 OR LESS” AND MADE TO AN INDIVIDUAL OR SOLE PROPRIETOR
BORROWER.
Preauthorized
Transfers from Deposit Account. If
a
deposit account number is provided in the following blank Borrower hereby
authorizes the Bank to debit Borrower’s deposit account
#______________________________with the Bank automatically for any amount which
becomes due under this Note.
Acknowledgment.
Borrower
acknowledges that it has read and understands all the provisions of this Note,
including the Confession
of Judgment, Governing Law, Jurisdiction
and
Waiver of Jury Trial,
and has
been advised by counsel as necessary or appropriate.
WITNESS
the due
execution hereof as a SEALED INSTRUMENT the day and year first above
written.
|
BORROWERS:
PAYMENTS,
INC.
|
|
|
______________(SEAL)
|
BY:_______________________(SEAL)
Name:
_____________________
Title:
______________________
|
|
DCAP
GROUP, INC.
|
|
|
______________(SEAL)
|
BY:_______________________(SEAL)
Name:
_____________________
Title:
______________________
|
[Acknowledgements
Follow on Next Page]
4
ACKNOWLEDGMENT
STATE
OF
_________________ )
:
SS.
COUNTY
OF
_______________ )
On
the
__________ day of July, in the year 2006, before me, the undersigned, a Notary
Public in and for said State, personally
appeared______________________________________, personally known to me or proved
to me on the basis of satisfactory evidence to be the individual(s) whose
name(s) is (are) subscribed to the within instrument and acknowledged to me
that
he/she/they executed the same in his/her/their capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the
instrument.
Notary
Public
STATE
OF
_________________ )
:
SS.
COUNTY
OF
_______________ )
On
the
__________ day of July, in the year 2006, before me, the undersigned, a Notary
Public in and for said State, personally
appeared______________________________________, personally known to me or proved
to me on the basis of satisfactory evidence to be the individual(s) whose
name(s) is (are) subscribed to the within instrument and acknowledged to me
that
he/she/they executed the same in his/her/their capacity(ies), and that by
his/her/their signature(s) on the instrument, the individual(s), or the person
upon behalf of which the individual(s) acted, executed the
instrument.
Notary
Public
FOR
BANK
USE ONLY
Authorization
Confirmed:
Disbursement
of Funds:
Credit
A/C # ____________________ Off
Ck #_________________
Payoff
Obligation #__________________
$ ____________________
$__________________ $___________________
