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In consideration of full payment of the debt shown by the promissory note dated Date , which set out the terms for repayment of a loan in the original principal amount of $$ Amount (the "Note"), Business / Individual we , the undersigned noteholders , of Street address , City , State , ZIP Code , release and discharge Name , of Street address , City , State , ZIP Code , from any claims or obligations arising out of the Note. This release relates only to the indebtedness evidenced by the Note and not to any other loan.
| Name | |
Date:__________________________________ |
By:______________________________________________________________ Name: Name Name Title: Title |
| Yes / No | |
| ACKNOWLEDGMENT | |
| OF NOTARY PUBLIC | |
| State of | ) |
| ) ss | |
| County of | ) |
On this _____ day of ____________, 20___, before me, the undersigned notary public, personally appeared _________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the state of _________________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature _______________________________ (notary public)