Affidavit Of Obligee Of Record Form

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AFFIDAVIT OF OBLIGEE OF RECORD
(Pursuant to La. R.S. 9:5168)
Louisiana
State of ______________________________
Jefferson
Parish/County of _______________________
Before me, undersigned Notary Public, personally came and appeared:
_____________________________________________________, hereinafter referred to as Affiant, who
after being duly sworn declared:
He/she is the obligee of record of that certain mortgage or vendor’s privilege which was granted
by __________________________________________________________________________________
in favor of ____________________________________________________________________________
which encumbers the following described property:
Lot(s) __________ Square __________ Subdivision ____________________________________
(Brief property description or described on attachment hereto made part hereof)
The above described mortgage or vendor’s privilege secures a paraphed promissory note
dated____________________________, in the original sum of $_______________________, payable to
the order of __________________________________________________________________________.
The above mortgage or privilege is recorded at MOB _________, folio __________, Instrument
Number ________________________ of the official records of Jefferson Parish, Louisiana.
If assigned, the assignment is recorded at MOB _______, folio_________ Instrument Number
___________________________.
(If necessary, add further assignment information on attachment hereto and made part hereof.)
Affiant further declared that:
1) the above described paraphed promissory note has been lost or destroyed and cannot be
presented;
2) the note is paid, forgiven or otherwise satisfied;
3) the note has not been sold, transferred or assigned to any other person or entity;
4) the Clerk of Court and Ex-Officio Recorder of Mortgages of Jefferson Parish, Louisiana is
hereby authorized to cancel the inscription of the above described mortgage or vendor’s privilege;
5) Affiant agrees to be personally liable to and indemnify the Clerk of Court and Ex-Officio
Recorder of Mortgages of Jefferson Parish, Louisiana and any person relying upon this cancellation by
affidavit for any damages that they may suffer as a consequence of such reliance if this recorded affidavit
contains incorrect statements that cause the recorder to incorrectly cancel the recordation of the above
mortgage or vendor’s privilege.
Signature: ____________________________________
Printed Name: ____________________________________
Mailing Address: _____________________________________________
City: ____________________________ State: ________ ZIP: _____________
Signature: ____________________________________
Printed Name: ____________________________________
Mailing Address: _____________________________________________
City: ____________________________ State: ________ ZIP: _____________
Sworn and subscribed before me this _______ day of __________________________ 20______.
______________________________________________
Notary Public
Printed Name: _______________________________________________________________
Notary Public or Bar Roll Number: _________ Commission expires: ___________________

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