I, _________________________, hereby acknowledge the receipt of
____________________________, the purchase price of which amounts to ________________, on _____________________. I understand that I will be accountable for any future loss or damage which will occur on the thing/s that I have received. I further agree to pay any cost that will be incurred for the replacement or repair of the above-mentioned thing in case of loss or damage provided that the occurrence of the loss or damage is caused by my negligence or intentional destruction. Damage or loss occurred without overt acts or negligence on my part, (e.g. damage due to the thing’s long existence or system default) shall be justified.
Received by:
________________________ _______________ Signature Over Printed Name Date