The Brown Company, Inc

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Promise-To-Pay Form

Debtor Name and Address

Address Line 1

Address Line 2

City

State

Zip Code

Invoice Number

Invoice Date

Original Due Date

Amount

Payment Method

Amount

Payment Due Date

Acknowledgement

Name

Date

Checkboxes

I have read and agreed to the Terms and Conditions.

and Acknowledgement Layout

Signature

Clear Signature

By signing above electronically, Debtor confirms that Debtor has read and understands the terms of this Promise to Pay Agreement, that Debtor is authorized to enter into this Agreement, and that Debtor’s electronic signature shall have the same force and effect as an original handwritten signature.