Single leaf, measuring 3½ × 7⅞ inches (9 × 20 cm), with eleven horizontal lines printed in blue ink. The top, bottom, and left sides of the recto were cut or torn from a larger sheet of paper. A second promissory note to dated 22 October 1842 was written on the larger sheet beneath this note; the two notes were likely torn apart after being signed. At some point, the document was trifolded and then folded in half widthwise. The note contains notations made in black ink and graphite.

After signed the note, likely retained it until 14 August 1846, when the bond accompanying this note was canceled. The note was then returned to the trustees-in-trust for the church, who presumably retained it among their financial papers. By 1973 the document had been included in the JS Collection at the Church Historical Department (now CHL).