Learn what an acknowledgement receipt is and how to create one for your business (with a template and two examples). On the _______day of ______ in the year_____, before me, the undersigned notary public, personally appeared.This document is a receipt acknowledging payment received from an individual or entity. This modification allows us to send an acknowledgment receipt and copy of filed image. Next, provide the name and signature of the person acknowledging receipt. Forms ; Summons extra caption. PDF ; Complaint sample. Explore the importance of acknowledgment letters in professional communication. Use our free template to acknowledge the receipt of emails, calls, or letters. Insurance company which is licensed to do business in the State of Connecticut.