$________________________

_________________________ (Date of Making)

_________________________ (Place of Making)

For value received I, __________________, of ______________________ (address), __________________ (city), _______________ (county), __________________ (state), promise to pay (or promise to pay to the order of) _____________________

at _____________________________ (address), _______________________ (city), ______________ (county), __________________ (state), on __________ (designate time payable, such as: _____ months after date without grace or on date, or if payable on demand, on demand) the sum of ________________ ($__________), with interest thereon at the rate of __________ percent (_____%) annually.

__________________________

(Signature of Maker)