Figure: 7 TAC §84.209(1)(A)

"(Optional:)DATE ______________________________)
BUYER ______________________________________	SELLER/CREDITOR______________________________
ADDRESS ____________________________________	ADDRESS ______________________________________
CITY _________________STATE______ ZIP _______	CITY ________________________ TX __ ZIP _________
PHONE _______________________________________	PHONE _________________________________________
(Optional Co-Buyer Identification) CO-BUYER ___________________________________
ADDRESS ____________________________________
CITY ____________________ STATE______ZIP_____
PHONE ______________________________________"