Credit Card Debt Acknowledgement Statement

Creditor Name:
Debtor Name:
Account Number (if applicable):
Statement

I, the undersigned, acknowledge that I owe the sum of to the creditor named above in respect of credit card debt. I confirm the accuracy of this debt and agree to the repayment arrangements as discussed.

Repayment Terms:
Debtor's Signature
Date
Creditor's Signature
Date