THE UNDERSIGNED, the owner and holder of......certain mortgage.., for......dollars,......and interest......dated the......day of.......

1-----, and recorded in the office of the........of the County of........on the......day of..........1-----, in liber......of mortgages, page......, in Section ........, which mortgage cover., certain premises situate in the which premises are also covered by a mortgage for ........ dollars and interest dated..........1...., and recorded in said........office on........,

1...., in liber......of mortgages, page ......in Section ......, which last mentioned mortgage is about to be assigned by........the holder thereof to

.......... hereby certifies, in consideration of one dollar paid and to enable said assignment to be made and accepted, that said last mentioned mortgage, so to be assigned, is a valid .......... lien upon the said premises for the full amount of principal and interest due thereon, namely, $...... with interest at...... per cent per annum from the ...... day of........, 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 last mentioned bond and mortgage are unmodified and in force.

Dated the......day of........ 192..

WITNESS, ...............................................................

(ACKNOWLEDGMENT)