Form 12a503 - Application For Specific Lien Release (Page 4 of 4) in pdf

Form 12a503 - Application For Specific Lien Release Page 4

(4)

(5)

(6)

Paid to:

____________________

___________________

____________________

___________________

____________________

___________________

Reason:

____________________

___________________

Amount:

____________________

___________________

10.

Furnish information to establish the value of the property for which the specific lien release is to

apply by submitting certified copies of TWO (2) professional appraisals. Include an estimate of

the fair market value of the property which will remain subject to the lien. In addition:

If public sale (auction) already held – give the date and place the sale was held, the amount

for which the property was sold, and the name and address of the purchaser(s).

B. If public sale (auction) to be held – give the proposed date and place of the sale, and include a

statement that the Department of Revenue will be paid in its proper priority from the proceeds

of the sale.

11.

Please list any additional properties you own and attach copies of the property deed(s).

"I DECLARE, UNDER PENALTIES OF PERJURY, THAT THIS APPLICATION HAS BEEN EXAMINED BY

ME AND, TO THE BEST OF MY KNOWLEDGE AND BELIEF, IT IS TRUE, CORRECT AND COMPLETE."

______________________________________

APPLICANT

Subscribed and sworn to before me this the _______ day of ________________, 200___.

______________________________________

NOTARY PUBLIC

My commission expires _________________________________________________________.

Form 12a503 - Application For Specific Lien Release Page 4