RECEIPT ON DISCHARGE OF STATUTORY OF LEGAL CHARGE OR MORTGAGE

I, A.B., of [.......................................] (Address) hereby acknowledge that I have this…………….day of………….……..20…………….. received the sum N………………………… representing the (aggregate) balance remaining owing in respect of the mortgage money secure by the (annexed) within (above) written statutory legal charge (for statutory mortgage) and (by the further charge dated, etc. or otherwise as required) together with all interest and cost the payment having been made by C. D. of……………….and of ……………….

IN WITNESS OF WHICH I HAVE EXECUTED THIS INSTRUMENT IN THE MANNER

BELOW THE DAY AND YEAR FIRST ABOVE WRITTEN

-------------------------------- A.B.

In the Presence of:

Name:

Address:

Occupation:

Signature: