Fill and Sign the New York Discharge Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: __________________ Company: __________________ Address: ____________________ City: _________________ State: _____ Zip: __________ Phone: _______________ Fax: ________________ Discharge of Lien – Individual (N.Y. Lien Law § 19) COMES NOW, _________________________________ , as a party who furnished labor and/or materials for the improvement of the property located at and described as _______________________________________________________________________ , whose address is ______________________________________________________________________ and would state as follows: 1. On or about the _____ day of _____________ , 20 ______ , the undersigned filed a Notice of Lien regarding the above described property. 2. On or about the _____ day of _____________ , 20 ______ , said lien was satisfied ( ) as to the whole of the above described property ( ) as to part of the above described property, said part being described as _______________________________________________________________________ . 3. By this certificate the undersigned lien claimant would wholly discharge and release said lien. This the _____ day of _____________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Discharge of Lien Page 1 of 2 STATE OF NEW YORK COUNTY OF ________________ On the _____ day of _____________ in the year _________ before me, the undersigned, personally appeared ____________________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ______________________________ Notary Public Printed Name: _________________ My Commission Expires: ______________ Discharge of Lien Page 2 of 2