Agreement made this ...... day of......, 19......., between

......, of......, hereinafter called the vendor, and......, of

......, hereinafter called the purchaser. Whereas, by a contract bearing date the......day of......, 19.........., the said vendor agreed to sell to the said purchaser, for the sum of......dollars, the parcel of land in said contract described; and whereas, in the course of investigating the title, it is found that there is an undischarged mortgage upon the said premises, and that the amount due upon said mortgage is in dispute, so that it can not be immediately discharged, but the said purchaser has agreed to complete said purchase immediately, on being allowed to retain the sum of

......dollars out of the purchase money until the said mortgage shall be satisfied and cancelled of record.

Now, these presents witness that, in pursuance of such arrangement, he, the said purchaser, hereby agrees to pay the remainder of said purchase money, and to complete the said purchase, whenever the said vendor shall cause said mortgage to be discharged, and until such time to pay interest on the said sum retained out of the purchase money, at the rate of......per cent. per annum.

And it is hereby mutually agreed that, in case the said vendor shall be unable or shall neglect to procure a discharge of said mortgage within ...... calendar months from the date hereof, the said sum of......dollars so retained as aforesaid out of the said purchase money shall be forfeited, and shall belong to the said purchaser, who shall be at liberty to retain the same to apply to the payment of said mortgage, so far as required, and as liquidated damages in respect of the said defect of title; and thereupon the said purchaser shall be no longer liable to pay or account for said sum, but shall be absolutely discharged therefrom, and the said vendor shall be discharged from all obligation to procure a discharge of said mortgage.

In witness whereof, etc.