This is to Certify that a certain Mechanic’s Lien, filed ...



This is to Certify that a certain Mechanic’s Lien, filed in the Office of the County Clerk of the County of New York, on the day of

20 in favor of claimant against the Building and Lot with the improvements thereon situated on

the side of

Street,

And known as No. in said Street, for the sum of $

claimed against

as owner(s)

and as

Is paid and satisfied, and the undersigned does hereby consent that the same be discharged of record.

DATED:

_______________________________________

_______________________________________

State of New York

County of ________________________

On the _______ day of ________ in the year _____ before me, the undersigned, a Notary Public in and for said State, personally appeared _________________________, personally known to me or proved to me on the basis of satisfactory evidence to the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

________________________________

Signature and Office of individual

taking acknowledgment

UNIFORM FORM CERTIFICATE OF PROOF OF EXECUTION BY A SUBSCRIBING WITNESS

(SUBSCRIBING WITNESS ACKNOWLEDGMENT)

State of New York

County of ________________________

On the _______ day of ________ in the year _____ before me, the undersigned, a Notary Public in and for said State, personally appeared _________________________, the subscribing witness to the foregoing instrument, with whom I am personally acquainted, who, being by me duly sworn, did depose and say that he/she/they reside(s) in _________________________ (if the place of residence is in a city, include the street and street number, if any, thereof); that he/she/they know(s) ______________________

to be the individual described in and who executed the foregoing instrument; that said subscribing witness was present and saw said _________________________ execute the same; and that said witness at the same time subscribed his/her/their name(s) as a witness thereto.

________________________________

Signature and Office of individual

taking proof

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