Form 12a503 - Application For Specific Lien Release Page 3

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(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.
8.
If a tax lien has been filed by the Internal Revenue Service, a copy of that lien, as well as the
specific lien release or letter of commitment given by the IRS MUST accompany this request.
9.
Itemize all anticipated actual costs, commissions, and expenses of the transfer or sale of the
property. (Additional space is provided on the next page.)
If a lien release is to cover real estate, a copy of the closing statement should be attached and
this section may be omitted.
(1)
(2)
(3)
Paid to:
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Reason:
____________________
____________________
____________________
Amount:
____________________
____________________
____________________

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