MORTGAGE REGISTRATION FEE AFFIDAVIT

K.S.A. 79-3102 (d)(3)

State Of _____________________

)

                                                    

)SS:

County Of ____________________

)

I, ______________________________ do state that I have personal knowledge of
               (print name of affiant)
the statements and representations set forth in this affidavit.
LIST MORTGAGES/INSTRUMENTS WHERE FEE PREVIOUSLY PAID:
Lenders Name Document No. Book or Volume Page No.

Amt of Indebtedness 

Paid On
         
         
         
         

Total Indebtedness Paid On    

  
Additional Information: __________________________________________________
___________________________________________________________________ 
NEW MORTGAGE/INSTRUMENTS TO BE RECORDED:
Lenders Name New Indebtedness
  $
Additional Indebtedness (New Indebtedness Less Indebtedness Previously Paid On)

$
                                                                             Affiant's Signature:

x___________________________

(___________________________________)  

                                                                                 Print Name
                          (Seal)

SUBSCRIBED AND SWORN TO before me on _________________________(date).

Expiration Date ________________      _______________________________  

                                                                                 Notary Public Signature
 Please attach copies of all referenced documents pages for timely processing.