Form Fm 4061 - Agreement For Cancellation Of Lease Page 2
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1
2Agreement for Cancellation of Lease
LEASE NO: ____________________ MODIFICATION NO:_______
IN WITNESS WHEREOF, the parties hereto have hereunto executed this instrument for the purpose herein expressed, this
______ day of ______________, _______.
ANY MODIFICATION OF A LEASE AGREEMENT SHALL NOT BECOME LEGALLY EFFECTIVE UNTIL
APPROVED/ACCEPTED BY THE DEPARTMENT OF MANAGEMENT SERVICES.
ORIGINAL SIGNATURES REQUESTED ON ALL COPIES
L
,
INDIVIDUAL
(
):
ESSOR
IF
S
Signed, sealed and delivered in the presence of:
(x)______________________________________
(x)_____________________________________(SEAL)
Witness Signature
________________________________________
Print or Type Name of Witness
________________________________________
(x)______________________________________
Print or Type Name
Witness Signature
(x)______________________________________(SEAL)
________________________________________
Print or Type Name of Witness
________________________________________
AS TO LESSOR
Print or Type Name
Signed, sealed and delivered in the presence of:
Name of Corporation, Partnership, Trust, etc.:
(x)______________________________________
Witness Signature
________________________________________
Print or Type Name of Witness
(x) _____________________________________ (SEAL)
(x)______________________________________
President, General Partnership, Trustee
Witness Signature
________________________________________
ATTEST: (x)____________________________ (SEAL)
Print or Type Name of Witness
Secretary
As to President, General Partner, Trustee
LESSEE:
Signed, sealed and delivered in the presence of:
STATE OF FLORIDA
______________________________________________
(x)______________________________________
Witness Signature
________________________________________
(x) ___________________________________________
Print or Type Name of Witness
(x)______________________________________
_________________________________________
Witness Signature
Print or Type Name
________________________________________
Print or Type Name of Witness
_________________________________________
AS TO LESSEE
Print or Type Title
A
A
F
L
,
S
O
T
A
A
F
L
,
S
O
PPROVED
S TO
ORM AND
EGALITY
UBJECT
NLY
O
A
A
T
C
N
T
PPROVED
S TO
ORM AND
EGALITY
UBJECT
NLY
PPROVED
S
O
ONDITIONS AND
EED
HEREFORE
F
P
E
P
T
F
P
E
P
ULL AND
ROPER
XECUTION BY THE
ARTIES
D
M
S
O
ULL AND
ROPER
XECUTION BY THE
ARTIES
EPARTMENT OF
ANAGEMENT
ERVICES
G
C
G
C
(x)______________________________
ENERAL
OUNSEL
ENERAL
OUNSEL FOR
D
Beth Sparkman,
EPARTMENT OF MANAGEMENT SERVICES
Chief Real Property Administrator
______________________________________
Division of Real Estate Development and
Management
(x) _________________________________
(x)__________________________________
(x)_____________________________,
Tom Berger ,
Director
Division of Real Estate Development and
___________________________________
_____________________________________
Management
Print or Type Name
Print or Type Name
A
D
:
___________________
PPROVAL
ATE
A
D
: ______________________
A
D
: ________________________
PPROVAL
ATE
PPROVAL
ATE
FM 4061 (R12/11)
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