LIEN RELEASE REQUEST

Part I - Request

1. To: ( lien service)

Assurance Lien Services, LLC.

Attn: Kelly Silvester

P. O. Box 160083

Clearfield, Utah 84016

kelly@lienservice.com

(801) 520-4500

2. From: (your company name)*

Mailing Address *

City *

State
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Zip Code

Phone*

3. Your name: *

Email*

4. Title:

5. Date Requested:

6. Date lien was filed*

7. Recorded Instrument Entry Number

8. Owners Name