Filed By: ______________________________ Telephone No:__________________________ DALE N. ATKINS CLERK OF COURT AND EX-OFFICIO RECORDER PARISH OF ORLEANS - STATE OF LOUISIANA MORTGAGE LIEN AND PRIVILEGE CERTIFICATE REQUEST NOTE: ALL REQUESTS FOR CERTIFICATES MUST BE IN WRITING. THIS CERTIFICATE WILL ONLY BE RUN IN THE EXACT NAME(S) PROVIDED, AND NOT IN ANY VARIATIONS OF THE SAME. WHERE NO MIDDLE INITIALS HAVE BEEN FURNISHED, IDENTICAL NAMES WITH MIDDLE INITIALS HAVE NOT BEEN RUN AND WILL NOT BE RUN UNLESS SPECIFICALLY REQUESTED. CONTRACT INSTRUMENT #____________________________________ ACCEPTANCE OR SUBSTANTIAL COMPLETION INSTRUMENT #___________________ OWNER NAME(S): CONTRACTOR NAME: JOB ADDRESS AND/OR PROJECT # DATE WORK STARTED: Requested by:__________________________ Print Name: ________________________ Date: _____________ Signature DO NOT WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkFlow.com