Prescribed Form For Release Of Lien

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PRESCRIBED FORM
FOR RELEASE OF LIEN
I (We) hereby certify that the lien or encumbrance on
VIN#
Year/Make/Model
Is / was hereby released on
.
Full payment of _____________ was made on _________ and hereby
fully satisfies the lien. These funds, in cash, have been received by the
below mentioned party (parties).
(PRINTED NAME OF LIENHOLDER)
(SIGNATURE OF LIENHOLDER OR AUTHORIZED AGENT)
(PRINTED NAME OF AUTHORIZED AGENT)
Lienholder’s Telephone Number:
Date Signed:
WARNING:
GEORGIA LAW PROVIDES THAT FALSIFYING
INFORMATION ON THIS FORM IS A THIRD - DEGREE FELONY.

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