State of Tennessee
County of
I, , do hereby solemnly swear (or affirm) that I am the true and lawful owner or holder of the note (or other instrument) secured by a lien created by an instrument which is of record in Deed (or Trust) Book , page , of the register's office of County, Tennessee; that I desire to make a marginal release of the lien securing the instrument (in whole or in part, as the case may be — specifying the extent); that the same has been fully paid (wholly or in part, as the case may be — specifying the extent) to me as such lawful owner and holder, and that I am unable to produce the original note (or other instrument) for the following reasons: (Here state briefly the facts showing why the secured instrument cannot be produced for cancellation, and that its loss, etc., was unintentional).
Owner or Holder of Note
Sworn to and subscribed before me, this the day of , 20 .
Register or Deputy