Request To Cancel Related Inscriptions Form

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REQUEST TO CANCEL RELATED INSCRIPTIONS
Insofar as the _________________________________________________________________________
Granted by or filed against: ___________________________________________________________________;
In favor of: _________________________________________________________________________________;
In the sum of: $_____________________; Dated: _______________________; Recorded in Mortgage Office
Book __________ Folio __________, instrument number __________________________, was previously
cancelled on _____________________, has been previously cancelled, the Clerk of Court and Recorder of
Mortgages for the Parish of Jefferson is hereby authorized, directed, and requested to cancel the
subsequently recorded related inscriptions described below.
[ ] Assumption
[ ] Assignment
[ ] Correction
[ ] Other ____________________________
Granted by or filed against: __________________________________________________________________;
In favor of: _________________________________________________________________________________;
In the sum of: $__________________________; Dated __________________________________;
Recorded in Mortgage Office Book ________ Folio ________, Instrument number ____________________.
[ ] Assumption
[ ] Assignment
[ ] Correction
[ ] Other ____________________________
Granted by or filed against: __________________________________________________________________;
In favor of: _________________________________________________________________________________;
In the sum of: $__________________________; Dated __________________________________;
Recorded in Mortgage Office Book ________ Folio ________, Instrument number ____________________.
[ ] Assumption
[ ] Assignment
[ ] Correction
[ ] Other ____________________________
Granted by or filed against: __________________________________________________________________;
In favor of: _________________________________________________________________________________;
In the sum of: $__________________________; Dated __________________________________;
Recorded in Mortgage Office Book ________ Folio ________, Instrument number ____________________.
[ ] Assumption
[ ] Assignment
[ ] Correction
[ ] Other ____________________________
Granted by or filed against: __________________________________________________________________;
In favor of: _________________________________________________________________________________;
In the sum of: $__________________________; Dated __________________________________;
Recorded in Mortgage Office Book ________ Folio ________, Instrument number ____________________.
The undersigned acknowledges that he/she is liable to and shall indemnify the Recorder of
Mortgages 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 La. R. S. 44:110.
_____________________________
__________________________________
DATE
SIGNATURE
PRINTED name of Above Signed Party: _____________________________________________
Company (if applicable): _____________________________________________
Title (if applicable): _____________________________ (Duly Authorized Agent)
Mailing Address: _____________________________________________
City: ________________________ State: ______ ZIP: _____________
e-Mail Address: ________________________________________________
Phone #: _________________________________________________

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