The following form is an example of the form which may be used to satisfy the disclosure requirements of subsection (b) of Code Section 10-1-682, requiring that the disclosures described in paragraphs (1), (2), (3), (4), (9), (12), and (13) of subsection (a) of Code Section 10-1-682 be made clearly, conspicuously, prominently, and together in sequence:

LEASE-PURCHASE DISCLOSURES

1. Description_of_leased_property: Item__Quantity__Serial_#__Mfg._Model__Condition ____ ________ ________ __________ _________ ____ ________ ________ __________ _________

2. Total_payment_due_at_beginning_of_contract: Lease payment: ____ Delivery charge: ____ Sales tax: ____ Other: ____ Total: ____

3. Lease_payments: 1. You may renew the lease weekly or monthly as you choose. 2. The weekly rental is $____. 3. The monthly rental is $____.

4. Other_charges: 1. Reinstatement fee $_____ 2. (Specify all others)

5. Cost_of_lease: If you renew this lease each week/month for ____ weeks/months, you will pay a total of $_____ to own this property. This total includes all costs included in the first lease payment.

6. Estimated_fair_market_value_of_the_leased_property: The estimated fair market value of the property you are leasing is $_____.

7. Cost_of_lease_services: The difference between the amount in item 5 and item 6 above is $_____. This is the cost of services to you under this lease if you elect to renew this lease for the number of terms necessary to acquire ownership of the leased property.

I have read the above statement before signing this agreement.

Date:_____________________ Lessee:______________________ Date:_____________________ Lessee:______________________