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The space above is reserved for REGISTER OF DEEDS
MORTGAGE REGISTRATION
FEE AFFIDAVIT
K.S.A. 79-3102 (d)(3)
STATE OF )
) SS:
COUNTY OF )
I, do state that I have personal knowledge of the statements and
(PRINT NAME OF AFFIANT)
representations set forth in this affidavit, and that the consideration stated in the mortgage tendered for filing is verified by this affidavit to be
principal indebtedness covered or included in the previously recorded mortgage(s) listed below with the same lender or their assigns upon which the
registration fee required by KSA 79-3101 et seq. has been previously paid.
LIST MORTGAGES/INSTRUMENTS WHERE FEE PREVIOUSLY PAID:
Lender’s
Document
Book
Page
Amt. of Indebtedness
Total Indebtedness Paid On
Additional Information:
NEW MORTGAGE/INSTRUMENT TO BE RECORDED:
Lender’s Name
New Indebtedness
$
Additional Indebtedness (New Indebtedness Less Indebtedness Previously Paid On)
$
Affiant’s Signature:
X
PRINT NAME
TITLE/COMPANY
(SEAL)
SUBSCRIBED AND SWORN TO before me on .
DATE
Expiration Date:
Notary Public
PLEASE ATTACH A COPY OF THE DOCUMENT PAGES THAT ARE REFERENCED FOR MOST TIMELY PROCESSING.