We, three sitting together as one court, were assembled, and there came before us R. Yisrael son of R. Shlomo, and he said to us: “I hereby transfer to you, Rabbi Abraham Cohen, Rabbi Yitzchak Levi, and Rabbi Yisrael Yisraeli , the judges here, every debt that is owed to me, and to my wife and to my sons and daughters , whether by written document or orally, so that they may collect them whenever they wish.”

And we have empowered them so that they may collect all their debts by means of this prozbul, in accordance with the enactment of our Sages, of blessed memory. And in witness thereof we have signed on the first day of the week, the twenty-ninth day of the month of Elul, in the year five thousand seven hundred and eighty-two from the Creation of the world; all is valid and confirmed.

Statement of Abraham Cohen, judge

Statement of Yitzchak Levi , judge

Statement of Yisrael Yisraeli, judge

Instructions:

The text in red should, of course, be adapted for each individual.

If a person is married, he should add “and to my wife”; if he has children who have a savings plan for each child [citizens of the State of Israel, a bank account, or any other debt], he should add “and to my sons and to my daughters.”

The names of the judges are the names of the three before whom the prozbul is executed.

The sample text assumes that the document is being executed on the eve of Rosh Hashanah 5783 [for example, a person who will not find three Jews on the eve of Rosh Hashanah, or someone who needs to undergo surgery and will be under anesthesia, or for any other reason]. If it is executed earlier, the date should be adjusted to the correct date.

Shulchan Aruch (Choshen Mishpat, sec. 67).