Cancellation By Affidavit Form
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1CANCELLATION BY AFFIDAVIT
(Pursuant to LA R.S. 9:5168)
STATE OF ______________________________
PARISH OF _____________________________
BE IT KNOWN that on this _____ day of _____________________, 20_____, before me the undersigned
Notary, duly commissioned and qualified in and for the above named Parish and State,
PERSONALLY CAME AND APPEARED:
_____________________________________________________________________ (Obligee of Record)
Represented herein by: ____________________________________________________________
Title: _____________________________, its duly authorized representative, who after being duly sworn
declared:
1.
The affiant is the obligee of record of the paraphed promissory note.
2.
The note has been lost or destroyed and cannot be presented.
3.
The note is paid, forgiven, or otherwise satisfied.
4.
The affiant has not sold, transferred, or assigned the note to any other person or entity.
The Clerk of Court and Ex-Officio Recorder of Mortgages in and for the Parish of Lafayette is hereby
requested, authorized and directed to cancel the recordation of the mortgage or vendor’s privilege.
Mortgage made by _______________________________________________________________________________
In favor of ______________________________________________________________________________________
In the sum of ______________________________________
Dated __________________________________
Registry Number ____________________________
Description of mortgaged property ___________________________________________________________________
_______________________________________________________________________________________________
The undersigned affiant agrees to be personally liable to and indemnify the Clerk of Court and Ex-Officio
Recorder of Mortgages of Lafayette Parish and any of its employees relying upon the Cancellation by
Affidavit for any damages they may suffer as a consequence of such reliance if the recorded affidavit
contains incorrect statements that cause the recorder to incorrectly cancel the recordation of a mortgage or
privilege.
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: ______________________
EFFECTIVE 8-15-08
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