Certificate of Acceptance
Lease Number __________________________
Supplier / Vendor Payment Authorization
Schedule Number _______________________
Lessee Name
We hereby acknowledge receipt of the Equipment described in the above-referenced Lease (the "Equipment") and
of Business __________________________________________
after full inspection of the Equipment have found it to be fully installed and in good working condition and satisfacto-
ry for all purposes of the applicable Lease Agreement or Lease Schedule we both signed. We hereby irrevocably
Equipment
authorize you to pay for and purchase the Equipment.
Location ____________________________________________
TO THE EXTENT THAT THE COST OF THE EQUIPMENT INCLUDES ANY MAINTENANCE/WARRANTY CON-
Authorized Signature (Corporate Officer, Owner, Partner)
TRACT, WE CLEARLY UNDERSTAND AND AGREE THAT YOU HAVE NO RESPONSIBILITY TO US OR ANYONE
ELSE IN CONJUNCTION WITH THE RESPONSIBILITIES AND OBLIGATIONS OF THE SUPPLIER WITH
X____________________________________
RESPECT TO THE MAINTENANCE/WARRANTY CONTRACT AND THAT YOU DO NOT AND WILL NOT ACCEPT
(Please sign upon delivery of equipment)
ANY OBLIGATION OF ANY TYPE TO PERFORM ANY SERVICE, REPAIR, REPLACEMENT OR MAINTENANCE
OF THE EQUIPMENT, AND THAT YOU ARE NOT A PARTY TO THE MAINTENANCE/WARRANTY CONTRACT. IN
ALL CIRCUMSTANCES, WE UNDERSTAND AND AGREE THAT WE WILL ONLY SEEK TO HAVE THE SUPPLIER
PERFORM UNDER THE MAINTENANCE/WARRANTY CONTRACT AND REGARDLESS OF ANY DISPUTE OR
Printed
DISSATISFACTION WE MAY HAVE WITH THE SUPPLIER OR THEIR SERVICES, WE AGREE TO CONTINUE TO
Name: ______________________________________________
PAY YOU ALL THE RENTALS DUE UNDER THE AGREEMENT AND THE PAYMENT DUE UNDER THIS LEASE
SCHEDULE.
Title:_______________________________ Date: __________
We understand that based on representations made by us herein and elsewhere, you are about to purchase the
Equipment and pay the Supplier.
WE HEREBY IRREVOCABLY AUTHORIZE YOU
TO PAY FOR AND PURCHASE THE EQUIPMENT

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