STATE of NEW YORK )
COUNTY of ERIE ) ss:
AFFIDAVIT REQUESTING EXEMPTION under TAX LAW §255
______________________________________________________, being duly sworn, depose and says:
1. That I am an attorney duly licensed to practice law in the State of New York with an office at
_____________________________________________________________________________;
2. That a supplemental instrument, namely a _____________________ dated ________________, is
about to be recorded in the Erie County Clerk’s Office, having been executed by the following
parties:
_____________________________________and _____________________________________;
3. That the following instruments have previously been recorded affecting the same or a portion of the
same indebtedness recited in the supplemental instrument:
a. ____________________dated _________, recorded __________ in Book _______, page______
in the face amount of $_____________ between _________________________ and
___________________________________upon which a mortgage tax of $___________ was
paid.
b. _______________________dated _____________, recorded _____________ in Book _____,
page______ in the face amount of $_____________ between _________________________
and ___________________________________upon which a mortgage tax of $___________
was paid.
4. That the maximum amount secured by all of the previously recorded instruments is $____________,
all of which amount has been loaned or advanced and has become secured thereby, except (if
applicable) $_______________;
5. That the present balance of principal indebtedness under such previously recorded instruments at
the date of execution of the supplemental instrument recited herein is $________________;
6. That no reloans or readvances have become secured under such previously recorded instruments,
except (if applicable)_________________________________________________;
7. That the total maximum amount of principal indebtedness secured by the supplemental instrument
and those instruments previously recorded is $_______________________.
WHEREFORE, deponent respectfully requests that this supplemental instrument be declared exempt
from taxation pursuant to the provisions of New York Tax Law §255.
Sworn to before me this _____ Name:________________________________________
day of ___________, ____.
_________________________________________
