I , residing at , , , being of legal age, depose and say that:
1. I am the owner of the dated secured by executed by , , , and recorded in ,, in , .
2. The note has been lost, misplaced, or destroyed and after the exercise or due diligence, the same cannot be located.
3. The note is in the amount of , with interest of % per annum. The Note provides for payments, beginning on and continuing thereafter until , when all remaining principal and interest is due. The outstanding balance on the note as of is which is inclusive of interest.
4. is the current holder of the Note and the Note, nor any part thereof, has not been assigned to any other person or entity.
5. A copy of the Note is attached hereto and it is a true and correct copy of the original Note.