UNIFORM REQUEST AND CANCELLATION AFFIDAVIT
(FOR MORTGAGES AND VENDOR’S LIENS)
PURSUANT TO LA R.S. 9:5166
STATE OF ____________
PARISH/COUNTY OF __________________
BE IT KNOWN THAT before me, the undersigned Notary Public, appeared:
(Corporate Title and Name of Entity If Applicable)
Its duly authorized agent hereinafter referred to as affiant, who after first being sworn declares that affiant is:
CHECK ONE BOX ONLY:
A notary public requesting cancellation under La. R.S. 9:5167(A)(1), herein declaring that affiant or someone under his
direction did satisfy the promissory note, and that the affiant or someone under his direction (1) received the note marked
“Paid in Full” from the last holder of the note, and that the note was lost or destroyed while in the affiant’s custody; or (2)
has confirmed that the last holder of the paraphed note received payment if full and send the note but the note was never
received, and that the affiant has made a due and diligent search for the note, the note cannot be located, and sixty days
have elapsed since payment or satisfaction of the note.
A duly authorized officer of a Louisiana licensed title insurer as defined in La. R.S. 22:46 of the Louisiana Insurance Code,
requesting cancellation under La. R.S. 9:5167(B)(1), herein declaring that all obligations secured by the mortgage or
vendor’s privilege have been satisfied, and that affiant has made a due and diligent search for the lost or destroyed
instrument which was sufficient to cause a cancellation of the mortgage or vendor’ privilege, that the lost or destroyed
instrument cannot be located, and that sixty days have elapsed since payment or satisfaction of the secured obligation.
An authorized officer of a title insurance business, the closing notary public, or the attorney for the person or entity which
made the payment requesting cancellation under La. R.S. 9:5167.1, herein declaring on behalf of the mortgagor or and
owner of the property encumbered by the mortgage that the mortgagee has received payment of the loan secured by the
mortgage in accordance with the payoff statement, as evidenced by (1) a bank check, certified check, or escrow account
check which has been negotiated by or on behalf of the mortgagee, or (2) other documentary evidence of the receipt of
payment by the mortgagee, including but not limited to verification that the funds were wired to the mortgagee, that more
than sixty days have elapsed since the date payment was received by the mortgagee and that the mortgagee has not
returned documentary authorization for cancellation of the mortgage; and that the mortgagee has been given at least
fifteen days notice in writing of the intention to execute and record an affidavit in accordance with La. R.S. 9:5167.1, with a
copy of the proposed affidavit attached to the written notice. Affiant declares that he has attached all evidence required by
law.
An obligee of record requesting cancellation under La. R.S. 9:5168, herein declaring that affiant is the obligee of record of
the mortgage or vendor’s privilege securing a paraphed promissory note and that the note has been lost or destroyed and
cannot be presented; that the note is paid, forgiven, or otherwise satisfied; and that affiant has not sold, transferred, or
assigned the note to any other person or entity. If affiant is not the Original Obligee of Record, but an Obligee of Record by
recorded Assignment of the inscription to be cancelled, a list of recorded Assignments is attached.
An obligee of record requesting release under La. R.S. 9:5169, declaring that affiant is herein acknowledging the
satisfaction, releasing or acknowledging the extinction of the mortgage or privilege. If affiant is not the Original Obligee or
Record, but an Obligee of Record by recorded Assignment of the inscription to be cancelled, affiant has attached a list of
recorded Assignments. JUDGMENTS OR LEGAL MORTGAGES MAY NOT BE CANCELLED USING THIS FORM.
An affiant requesting cancellation under La. R.S. 9:5170, here declaring that he is attaching herewith
the paraphed obligation marked “PAID” or “CANCELLED”; or
an authentic act of release conforming to the requirements of La. R.S. 91570(A) (2).
A duly authorized officer of a Licensed Financial Institution under La. R.S. 9:5172, herein declaring that the institution was
the obligee or the authorized agent of the obligee of the obligation secured by the mortgage or privilege when the
obligation was extinguished and that the secured obligation has been paid or otherwise satisfied or extinguished; or that
the institution is the obligee or authorized agent of the obligee of the secured obligation and that it releases the mortgage
or privilege and directs the recorder to cancel its recordation.