This contract entered into this--------- day of ---------, 19 -, by and between

A. B. of the City of ---------, State of ---------, party of the first part, and C. D.

of the City of ---------, State of ---------, party of the second part, Witnesses:

Whereas, on or about the --------- day of ---------, 19 -, the said A. B. was indebted to the said C. D. upon [state nature of the claim] in the sum of

---------dollars; and whereas, subsequently thereto, on the ---------day of---------,

19 -, said A. B. was duly adjudged a bankrupt in bankruptcy proceedings had before the [insert court before which such proceedings were had], and whereas said A. B. thereafter on the---------day of---------, duly received his discharge in bankruptcy; and whereas said A. B., notwithstanding such discharge wishes to pay said debt due to said C. D.; now the said A. B. in consideration of the foregoing premises does hereby agree to pay to said C. D. the said sum of --------- dollars, upon the --------- day of ---------, 19 -.

In witness whereof, etc.

For a debt, barred by bankruptcy, as a consideration, see Sec. S 634 and 3166.

If the creditor has received a dividend in the bankruptcy proceedings, the contract should recite the amount of such dividend; and the amount thereof should be deducted from the principal and interest of the original debt.

If it is intended to pay such debt in instalments, the contract should set forth the amount of each instalment and the time at which it is to be paid.

Debt barred by bankruptcy as consideration for new promise, Sec. 632, 3166 and 3166 et seq.