TO ACCOMPANY PROMISSORY NOTE PER TITLE 45-721 (C)(2):
"KNOW ALL BY THESE PRESENTS:
"THAT I, the undersigned, hereby certify under penalties of perjury that:
"1. I am (the last known holder of the attached promissory note marked "Paid" or "Cancelled") or (an officer of the undersigned title insurance company) or (a validly licensed title insurance agent) which disbursed funds in payment of the promissory note;
"2. the attached promissory note has been fully paid, cancelled or satisfied; and
"3. the deed of trust dated _________ securing said promissory note granted by
_________________ in favor of __________________ securing ________________
and recorded in the land records on ___________ in Liber _______ at Folio _______
as Instrument No. ______ and constitution a lien upon that piece or parcel of land located in the District of Columbia and known as:
"LOT _______ in SQUARE _______ (additional legal description, ex.
subdivision) as per plat recorded in Liber ________ at Folio ________ among the land records is hereby RELEASED.
"WITNESS the hand and seal of the undersigned ______________________________
this _______ day of ___________, ____.
"STATE/DISTRICT of _______________ )
"COUNTY of _______________ )
"I the undersigned, a Notary Public in and for the aforesaid do hereby certify that
______________________ party to and who is personally well known to me as the person who executed the foregoing Release Affidavit dated the ____ day of ___________, ______, personally appeared before me in said jurisdiction and acknowledged the same to be his/her/its act and deed.
Given under my hand and seal, this ____ day of _________, ____, and:
"My commission expires:
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