In the presence of the undersigned three judges (dayanim), duly constituting a Bet Din, there appeared before us
who declared before us as follows:
“I hereby turn over to you judges [insert names] , and
, in this place [insert place name] all of the debts owed to me, whether or not the debts are evidenced in writing, so that I may therefore collect these debts at any time that I desire.”
We the undersigned Bet Din heard the declaration of the above-described person and have empowered such person to avoid having his (or her) debts canceled by shmitta and he (or she) may therefore collect all of his (or her) debts by virtue of this Pruzbul in accordance with the special enactment of Hillel and Chazal.
IN WITNESS WHEREOF, we hereby affix our signatures this day of , 5775, here in
Signed: , dayan Signed: , dayan Signed: , dayan