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Fill and Sign the Column a Column B New York State Department of Taxation Form

Fill and Sign the Column a Column B New York State Department of Taxation Form

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Affidavit for Cancellation of Preliminary Lien Notice Page 1 of 2Prepared by, recording requested by and return to:Name _____________________________Street __________________________Address ____________________________City _________________________State ______________Zip ____________________Phone __________________________------------------------------------Above this line for Official Use Only ----------------------------------- AFFIDAVIT FOR CANCELLATION OF PRELIMINARY LIEN NOTICE- CORPORATION STATE OF GEORGIACOUNTY OF ______________________ BE IT KNOWN THAT _________________________________, upon being duly sworn, states on oath the following:1. A demand was filed for filing of a claim of lien to __________________________________, in connection with the Preliminary Lien Notice filed by __________________________. The demand was filed in accordance with 44-14-361.4(a) (3) or (4). The demand was mailed by registered or certified mail or statutory overnight delivery on _____ day of _________________, 20______. 2.A true and correct copy of the Demand to File a Claim of Lien is attached hereto as Exhibit "A" and incorporated herein by reference.3.Ten (10) days has elapsed since the date of mailing of the Demand to file a Claim of Lien without the filing of a claim of lien by the potential lien claimant.4.The Clerk of Superior Court is therefore requested to cancel of record the preliminary notice of lien rights filed by ___________________________________.WITNESS my signature this the _____ day of __________________, 20_____.__________________________________________Signature Printed Name: ______________________________Title: _____________________________________Name of Corporation: ________________________ Attest: Secretary Affidavit for Cancellation of Preliminary Lien Notice Page 2 of 2Sworn to and executedin the presence of:_______________________ (Witness)Sworn to (or affirmed) and subscribed before me this ____ day of __________ (month), __________ (year), by _______________________ (name of person making statement)._______ Personally Known_______ Produced IdentificationType and # of ID __________________________ ____________________________(Signature of Notary) (Seal) _____________________________ (Name of Notary Typed, Stamped or Printed) Notary Public, State of GeorgiaMy Commission Expires: ______________ Reference 44-14-361.4.

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