Company Name, a Delaware corporation (the “Company”), hereby acknowledges receipt of:
- A check in the amount of $Check Amount
- The cancellation of indebtedness in the amount of Indebtedness Cancelled
- A Promissory Note in the amount of $Promissory Note Amount
- Services rendered having a value equal to $Service Rendered Value
- The assignment of certain intellectual property and/or other assets having an aggregate value equal to $IP or Other Asset Value
given by Transferor Name as consideration for Certificate No. CS-Certificate No. for Purchased No. shares of Common Stock of the Company.
Dated: Date Receipt Was Signed