[Date]

[Address]


FOR VALUE RECEIVED, the undersigned does hereby sell, 
assign and transfer to [Name of  Assignee], its successors 
or assigns, all right, title and interest of the undersigned in and 
to a certain security interest and debt thereto issued to the 
undersigned from [Name of Debtor], under date of [Month, day], 
[Year], all as annexed hereto. 

Signed under seal this [date] day of [month, year]. 


________________________________________
(clearly print name after signature)