Fill and Sign the Tennessee Acknowledgment Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: __________________ Address: _____________________ City: ________________ State: ______ Zip: __________ Phone: _________________ Fax: __________________ Reference Instrument Number: ________________ ACKNOWLEDGEMENT OF SATISFACTON OF LIEN-INDIVIDUAL (Tenn. Code Ann. § 66-11-135) This instrument was prepared by: Name: ___________________________________ Address: _______________________________________________________________ COMES NOW, __________________________________ , as a party claiming a lien on the property described as _______________________________________________________________________ , and would state as follows: 1. The undersigned recorded a lien against the above described property, owned by ___________________________________ , on the _____ day of _____________ , 20 _________ , in the amount of $ _____________ . The reference instrument number is _______________ and the office, book and page number is _______________ . 2. The undersigned hereby acknowledges that on or about the _____ day of _____________ , 20 _______ , the undersigned received a payment from ____________________________________ in the amount of $ ____________ . 3. Said amount represents payment in full for labor performed and/or materials furnished by the undersigned for the following described improvements and/or materials, ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 4. By this document the undersigned lien claimant hereby releases any lien he or she may have in connection with the above - described property for labor performed and materials furnished and acknowledges the satisfaction thereof. This the _____ day of _____________ , 20 ______ . Acknowledgement of Satisfaction of Lien Page 1 of 2 __________________________________ Signature of Lien Holder _____ _____________________________ Type or Print Name State of Tennessee County of __________________ Personally appeared before me, the undersigned, a Notary Public within and for said State and County aforesaid, duly commissioned and qualified, ________________________ , the within named bargainers, with whom I am personally acquainted, or proved to me on the basis of satisfactory evidence, and who acknowledged that they executed the foregoing instrument for the purposes therein contained. Witness my hand and seal at office this ______ day of __________________ , 20 ______ . Notary Public My commission expires:       Type or Print Name Acknowledgement of Satisfaction of Lien Page 2 of 2