THE UNDERSIGNED, owning the premises situate in the .............., shown on the following diagram

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covered by a mortgage for $........ and interest, dated ........, 1 ...., and recorded ........ in the office of the ........of the County of ........, in liber ......, page......, of mortgages, in Section......, which mortgage is about to be assigned by.......... the holder to ..........; hereby certifies, in consideration of one dollar paid and to enable said assignment to be made and accepted, that said mortgage, so to be assigned, is a valid...... lien on said premises for the full amount of principal and interest due thereon, namely $........ with interest at ...... per cent per annum from ........, 19...., and that there are no defenses or offsets to said mortgage, or to the bond which it secures.

The undersigned further certifies that all the other provisions of said bond and mortgage are unmodified and in force.

Dated ...... day of............ 19....

WITNESS,

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(ACKNOWLEDGMENT)