RELEASE BY OBLIGEE OF RECORD OF A MORTGAGE
OR VENDOR’S PRIVILEGE
(PARAPHED PROMISSORY NOTE – PURSUANT TO LA. R.S. 9:5168)
TO:
CLERK OF COURT AND RECORDER
STATE OF LOUISIANA / PARISH OF TERREBONNE
BEFORE ME, the undersigned, duly commissioned and qualified Notary Public, personally came and
appeared:
__________________________________________________________________________________
who after being duly sworn, did depose and say that:
He/She is authorized to make and execute this affidavit as stated or provided for under R.S. 9:5168. The
affiant is the Obligee of Record of the paraphed promissory note described as follows:
Dated: _____________________________________
in the amount of $ ____________________________
Executed by: (Mortgagor) ________________________________________________________________________
In favor of:
_______________________________________________________________________________
Recorded in Mortgage Book No. ______________, folio _______________ Entry # _________________________
Legal Description is as follows or is hereby attached as Exhibit “A”
_____________________________________________________________________________________________
_____________________________________________________________________________________________
The Note has been lost or destroyed and cannot be presented.
The Note is paid, forgiven or otherwise satisfied.
The Affiant authorizes the Clerk of Court and Ex-Officio Recorder of Mortgages to cancel the inscription
of the Mortgage or Vendor’s Privilege.
The Affiant has not sold, transferred, or assigned the note to any other person or entity.
The undersigned authority acknowledges that he/she is personally liable to and shall indemnify the Clerk of
Court and Recorder of Mortgages of Terrebonne Parish and any person relying on this Request for Cancellation for
any damages they may suffer as a consequence of such reliance in accordance with the provisions of R.S. 44:110.
Mailing Address (Of Party Making Request)
__________________________________________________
Signature of Affiant
__________________________________
__________________________________________________
Printed Name of Affiant
__________________________________
__________________________________________________
Title of Affiant/Company
__________________________________
Telephone # _______________________
Sworn to and subscribed before me, Notary Public, on
this _______________ day of
____________________________, __________.
_____________________________________________________
Notary Public
_____________________________________________________
Printed Name of Notary / ID Number
5/2012
1
Affidavit Of Lost Paraphed Promissory Note & Authorization To Cancel Mortgage (by Notary Public) Form
Legal
