__________________________________________________, BEING DULY SWORN AND SAYS:

 1. I AM FULLY FAMILIAR WITH THE FACTS SURROUNDING THE MORTGAGE BEING SUBMITTED HEREIN FOR RECORDING NAMELY:

MORTGAGOR: _____________________________________________

MORTGAGEE: _______________________________________________

PROPERTY ADDRESS : ______________________________________________

DATED: ________________________ AMOUNT: ________________________

2. THAT THE MORTGAGEE IS A NATURAL PERSON. 

3. THAT THE PREMISES BEING MORTGAGED IS IMPROVED BY A SINGLE FAMILY DWELLING.

 4. THAT BASED UPON THE AFOREMENTIONED FACTS, THIS MORTGAGE QUALIFIES TO EXEMPT THE MORTGAGEE FROM PAYING THE º OF 1% OF ADDITIONAL MORTGAGE TAX.

 5. I MAKE THIS AFFIDAVIT KNOWING THAT THE STATE OF NEW YORK AND THE ROCKLAND COUNTY CLERK’S WILL RELY UPON THE REPRESENTATIONS MADE HEREIN WHEN EXEMPTING THE MORTGAGE FROM THE ADDITIONAL MORTGAGE TAX.

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(MORTGAGEE’S SIGNATURE)

_____________________________________________________ 

SWORN TO BEFORE ME THIS ________________ DAY OF ________________, 19_____.

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NOTARY