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Form 12a502 - Application For Certificate Of Subordination Of Kentucky Department Of Revenue Lien Page 3

(4)

(5)

(6)

Name &

____________________

___________________

Address:

____________________

___________________

____________________

___________________

Description:

____________________

___________________

Date Recorded:

____________________

___________________

*Amount Due:

____________________

___________________

*Attach a written statement for each creditor holding a superior lien attesting to the balance due.

If a tax lien has been filed by the Internal Revenue Service, a copy of that lien, as well as the

certificate of subordination or letter of commitment given by the IRS MUST accompany this

request.

10.

Furnish information to establish the value of the property for which the certificate of

subordination is to apply by submitting certified copies of TWO (2) professional appraisals.

Include an estimate of the fair market value of the property which will remain subject to the lien.

11.

Reason for Request.

12.

Please list any additional properties you own and attach copies of the property deed(s).

"I DECLARE, UNDER PENALTIES OF PERJURY, THAT THIS APPLICATION HAS BEEN EXAMINED BY

ME AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS TRUE, CORRECT AND COMPLETE."

______________________________________

APPLICANT

Subscribed and sworn to before me this the _______ day of ________________, 200___.

______________________________________

NOTARY PUBLIC

My commission expires _________________________________________________________.

Form 12a502 - Application For Certificate Of Subordination Of Kentucky Department Of Revenue Lien Page 3