______________________________ (date)

To: ____________________________________ (name of bailee)

_______________________________________ (address)

ACKNOWLEDGMENT OF RECEIPT OF GOODS

The undersigned warrants that __________ (he or she) is the person entitled to delivery of the goods under __________________ (bill of lading) number ________, issued by you and dated __________, and here acknowledges the delivery and receipt of the property described in that document and any supplemental list as follows: ______________________________________.

The undersigned further warrants that the goods so received on this date were in apparent good order except as otherwise noted here: __________.

The delivery and receipt of these items constitutes delivery of all goods owned by the undersigned and stored with the bailee except as follows: ______________ (Set forth numbers of other outstanding receipts or indicate nature of goods remaining in storage). Executed: _______________________ (date)

_______________________________________________________

Signature