_________ has acted as agent for many years for my late spouse _________, and after his or her death for me, in the loaning of certain money for us and in our behalf; and he or she is now holding for me notes as hereafter described; and he or she has executed the one note dated [date] for $_____ payable to me, pledging as collateral the notes referred to above, namely: _________[state amounts and makers and maturity of notes].

The note for $_____ is really not the personal obligation of _________ but is given only to protect me from loss upon the notes _________ has taken for my account.

In consideration of the premises, I by this means agree to hold the note for $_____, and not to transfer or dispose of it without the consent in writing of _________.

I further agree that the collateral notes referred to shall be held by _________; and he or she is by this means impowered to control, renew or extend them, and to substitute for them other collateral at his or her discretion.

I also agree to exhaust my collateral, whatever it may be, before demanding payment from _________ of any part of this obligation, or attempting to collect any part of his or her personal note, unless there should be a loss in the collateral referred to, in which case he or she shall be liable for such deficiency.

Provided, however, that _________ shall pay _________, annually, interest at the rate of _________ percent upon the whole or such part of the principal as may be unpaid from time to time.