State of Tennessee
County of ______________
I, ______________, do hereby solemnly swear (or affirm) that I am the true and lawful owner or holder of the note (or other instrument) secured by a lien created by an instrument which is of record in Deed (or Trust) Book ____________________, page ____________________, of the register's office of ____________________ County, Tennessee; that I desire to make a marginal release of the lien securing the instrument (in whole or in part, as the case may be - specifying the extent); that the same has been fully paid (wholly or in part, as the case may be - specifying the extent) to me as such lawful owner and holder, and that I am unable to produce the original note (or other instrument) for the following reasons: (Here state briefly the facts showing why the secured instrument cannot be produced for cancellation, and that its loss, etc., was unintentional).
______________ Owner or Holder of Note
Sworn to and subscribed before me, this the ____________________ day of ____________________, 20____________________.
______________ Register or Deputy
T.C.A. § 66-25-207