Cancellation Of Mortgage Lost Or Destroyed Promissory Note Proof By Affidavit (La R.s. 9:5167) By Notary Form

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CANCELLATION OF MORTGAGE
LOST OR DESTROYED PROMISSORY NOTE
PROOF BY AFFIDAVIT (LA R.S. 9:5167)
BY NOTARY
STATE OF _________________________________
PARISH OF ________________________________
BEFORE ME, personally came and appeared the undersigned who, being by me first duly sworn,
deposed and said that:
1.
The
Affiant
was
the
holder
of
the
promissory
note
signed
by
______________________________________________________________________
(Mortgagor)
dated _____________________________________________, in the principal amount of
$___________________________________________________
drawn
to
the
order
of
_____________________________________________________________________(
Mortgagee);
said promissory note being secured by mortgage or vendor’s lien, recorded in Mortgage Book
No. ____________, folio ____________, Entry Number ____________________, of the records
of Terrebonne Parish, Louisiana, on the property described on the attached exhibit.
2.
The Affiant, a Notary Public, who satisfied the promissory note out of the proceeds of an act of
sale or mortgage executed before him, is the last holder of the promissory note.
3.
The Affiant did receive the note, marked “PAID IN FULL” from the last holder of the Note.
4.
The Note has been lost or cannot be presented.
5.
The Note is paid.
6.
The Affiant authorizes the Clerk of Court and Ex-Officio recorder of Mortgages to cancel the
mortgage or vendor’s lien.
7.
The Affiant has not sold, transferred, or assigned the note to any other person or entity.
8.
Affiant has made a due and diligent search for the last holder, the last holder cannot be located,
and one year has elapsed since recordation of the act of sale or mortgage giving rise to the
affidavit of cancellation.
9.
The Affiant agrees to indemnify any person or entity for any damages resulting to any person or
entity as a consequence of canceling the mortgage or vendor’s lien pursuant to this affidavit.
By:________________________________________
(Signature of Affiant)
___________________________________________
(Printed Name of Affiant)
SWORN TO AND SUBSCRIBED BEFORE ME THIS _________ DAY OF ____________________, _______
_________________________________________________
NOTARY PUBLIC
5/2012

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