Request For Cancellation Of Mortgage Or Privilege And Release By Licensed Financial Institution Pursuant To R.s. 9:5172 Form
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1REQUEST FOR CANCELLATION OF MORTGAGE OR PRIVILEGE AND RELEASE
BY LICENSED FINANCIAL INSTITUTION
PURSUANT TO R.S. 9:5172 (Formerly R.S. 44:109)
STATE OF
_________________________________
PARISH OF
_________________________________
BE IT KNOWN that on this ____________ day of _________________________________, 20________,
Before me, the undersigned Notary Public appeared:
______________________________________________________________________________________
Name of Financial Institution
Herein represented by its undersigned duly authorized representative, which declared that it is a licensed financial
institution as defined in R.S. 9:5172 et seq. and that one of the following statements is true and correct:
(1) The institution was the obligee or the authorized agent of the obligee of the obligation secured by the
Mortgage or Privilege described below when the obligation was extinguished, and the secured
obligation has been paid or otherwise satisfied or extinguished; or
(2) The institution is the obligee or authorized agent of the obligee of the secured obligation, and it
Releases the Mortgage or Privilege described below.
The Clerk of Court and Ex-Officio Recorder of Mortgages for the Parish identified below is hereby expressly
requested, authorized, and directed to cancel the recordation of the mortgage or privilege described as
follows:
A Mortgage or Privilege granted by ______________________________________________________________
In favor of ___________________________________________________________________________________
Date of Instrument:_________________________________ Parish of Recordation:_______________________
Amount of Mortgage/Privilege: $ _______________________________
Recording Data: MOB _______________ FOLIO _______________ ENTRY NUMBER ________________
LEGAL DESCRIPTION IS AS FOLLOWS OR IS HEREBY ATTACHED AS EXHIBIT “A”
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(3) The Recorder of Mortgages shall not be liable for any damages resulting from any person or entity as a
Consequence of canceling a Mortgage or Vendor’s Privilege pursuant to this form.
THUS DONE AND PASSED before me, Notary Public, on the date set forth above.
__________________________________________________
SIGNATURE OF OFFICER
__________________________________________________
PRINTED NAME OF OFFICER
__________________________________________________
NAME OF FINANCIAL INSTITUTION
__________________________________________________
REQUESTED MAILING ADDRESS
__________________________________________________
CITY, STATE AND ZIP CODE
__________________________________________________
Notary Public
Printed Name of Notary: ______________________________
Bar Roll or Notary ID # _______________________________
5/2012
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