Request For Cancellation By Licensed Financial Institution Form
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1REQUEST FOR CANCELLATION BY LICENSED FINANCIAL INSTITUTION
(Pursuant to R.S. 9:5172 formerly 44:109)
STATE OF ______________________________
PARISH OR COUNTY 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 said secured obligation has been paid or otherwise satisfied or extinguished and further the said
mortgage or privilege is hereby released.
The Recorder of Mortgages in and for the Parish of Lafayette is hereby requested, authorized and directed
to cancel the recordation of the mortgage or privilege described as follows:
Mortgage or Privilege made by ____________________________________________________________________
In favor of ______________________________________________________________________________________
In the sum of ______________________________________
Date of instrument ________________________
Registry Number _______________________
Legal description is as follows or is hereby attached as Exhibit “A”
________________________________________________________________________________________________
________________________________________________________________________________________________
The undersigned acknowledges that he is liable to and shall indemnify the Recorder of Mortgages of
Lafayette Parish and any of its employees relying on this Cancellation for any damages they may suffer as
a consequence of such reliance in accordance with provisions of R.S. 9:5174.
WITNESSES:
SIGNATURE: ____________________________________
PRINTED NAME: _________________________________
_________________________
COMPANY NAME: _______________________________
TITLE: __________________________________________
ADDRESS: _______________________________________
_________________________
__________________________________________________
TELEPHONE NO: ________________________________
Sworn to and subscribed before me this _____ day of ___________________________, 20 ______.
__________________________________________
Notary Public
Printed Name: ____________________________
ID or Bar Roll Number: ____________________
Commission Expires: ______________________
Revised 7-26-2012
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