Fill and Sign the Discharge Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: ____________________ City: ___________________ State: _____ Zip: __________ Phone: _________________ Fax: __________________ CERTIFICATE TO DISCHARGE LIEN CLAIM OF RECORD—INDIVIDUAL- RESIDENTIAL TO: Clerk of __________________ County The below named Claimant, located at ________________________________________________________________________ (address of Claimant), hereby directs you to discharge of record the following lien: Lien Claim filed on the _____ day of ________________ , 20 ______ , at Book _______ , Page ______ in the amount of ___________________ dollars, for the value of work, services, material or equipment, in accordance with a contract between Claimant and ________________________________ . The owner of the property upon which the lien was filed is _______________________________ , said property being located in _________________ County, New Jersey, and being described as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ [Describe Property or Attach Exhibit] The written contract is a residential construction contract as defined in section 2 of this act. The claim has been paid/satisfied/settled by the parties/ forfeited by the claimant. This the _____ day of ______________ , 20 ______ . Certificate to Discharge Lien Claim of Record Page 1 of 2 Signed, sealed and delivered in the Presence of or Attested by: ____________________________ ____________________________ (Seal) Lien Claimant _____ _______________________ Type or Print Name ____________________________ State of New Jersey County of _________________ , ss: I CERTIFY that on ___________________ , ______________ , __________________________________ personally came before me and acknowledged under oath to my satisfaction, that this person (or if more than one, each person): a) is named in and personally signed the attached document; and b) signed and delivered this document as his/her/their act and deed. _______________________________ Claimant ______________________________ Notary Public Print Name: ___________________ My commission expires: _______________ NJ § 2A:44A-30 Certificate to Discharge Lien Claim of Record Page 2 of 2