Settlement of Disputed Account

Settlement Agreement by and between ___________________________________ (Creditor), whose address is ________________________________________________________________ and _________________________________________ (Debtor), whose address is __________________________________________________________________.

Whereas, Creditor asserts to hold certain claim against Debtor in the amount of __________ dollars ($ ), arising from the below described transaction:

And whereas, Debtor disputes said claim, and denies said debt is owed to creditor.

And whereas, the parties desire to resolve and forever settle and adjust said claim.

Now, therefore, Debtor agrees to pay to Creditor and Creditor agrees to accept from

Debtor, the sum of _______________________ dollars ($ ) in full payment, settlement, satisfaction, discharge and release of said claim. Creditor agrees that it will not

file an adverse report against Debtor with any credit bureau in connection with this claim.

This agreement shall be binding upon and inure to the benefit of the parties, their

successors, assigns and personal representatives.

Signed this _____ day of _______________________, 19____.

____________________________________

Creditor

____________________________________

Debtor

Subscribed and sworn to me by the above named parties on this _____ day of ____________, 20__.

Witness my hand and seal:

____________________________________ My Commission Expires:

Notary Public