Fill and Sign the Louisiana Cancellation Form 497308528

REQUEST FOR CANCELLATION OF CLAIM AND PRIVILEGE INDIVIDUAL (La.Rev.Stats § 9:4833) COMES NOW, __________________________________, as a person who has filed a Statement of Claim and Privilege on the _____ day of __________________, 20______ and whose address is ________________________________________________________________, to hereby request that the recorder of mortgages cancel the Statement of Claim and Privilege from his or her records, and would provide the following: (1) On the _____ day of __________________, 20______, the undersigned received a written request from ___________________________________, as Owner or other interested person to give this Request as the Statement of Claim and Privilege had either been improperly filed or the claim or privilege preserved by the filing of the Statement of Claim and Privilege had been extinguished. (2) The undersigned is delivering this Request within ten (10) days of receipt of such written request. This the _____ day of ______________, 20_________. ________________________ Signature ________________________ Type or Print Name Request for Cancellation of Claim and Privilege Page 1 of 2 STATE OF LOUISIANA COUNTY OF ___________________ On this _______ day of ________, 20__, __________ before me personally appeared _______________________________, to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that he or she (or they) executed it as his or her (or their) free act and deed. ______________________________ Notary Public ______________________________ Type or Print Name ______________________________ Title (and Rank) (Seal, if any) My appointment expires: ___________________ Request for Cancellation of Claim and Privilege Page 2 of 2