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Note: We are not attorneys, cannot prepare forms for you, practice law or give you legal advice. These forms are samples and they are for information only. We recommend always that you employ competent legal counsel.

AFFIDAVIT OF MORTGAGE PAYMENT HISTORY

(State of: ____________________) SS:

(County of: ____________________)

BEFORE ME, the undersigned authority, duly authorized in the state and county aforesaid to take acknowledgements, this day personally appeared the undersigned Affiant(s), , jointly and severally if more than one (hereinafter referred to collectively as "Affiant"), who, first being duly sworn, depose(s) and say(s):

(1) Affiant is the holder of that certain Note and Mortgage, dated , 19 , and recorded in Volume , Page(s) , of the County records, State of , encumbering property located at .

(2) Affiant has been personally responsible for the receiving of payments and servicing of said Note and Mortgage for the time period starting , 19 , thru and including the date hereof.

(3) The following table represents a true and accurate accounting of the payment history for said Note and Mortgage:

	Payment Due Date	Amount $ Due	Amount $ Received	Comments/ Explanations
1.	______	____	_____	________
2.	______	____	_____	________
3.	______	____	_____	________
4.	______	____	_____	________
5.	______	____	_____	________
6.	______	____	_____	________
7.	______	____	_____	________
8.	______	____	_____	________
9.	______	____	_____	________

10.	______	____	____	_______
11.	______	____	_____	________
12.	______	____	_____	________
13.	______	____	_____	________
14.	______	____	_____	________
15.	______	____	_____	________
16.	______	____	_____	________
17.	______	____	_____	________
18.	______	____	_____	________
19.	______	____	_____	________

20.	______	____	____	_______
21.	______	____	_____	________
22.	______	____	_____	________
23.	______	____	_____	________
24.	______	____	_____	________
25.	______	____	_____	________
26.	______	____	_____	________
27.	______	____	_____	________
28.	______	____	_____	________
29.	______	____	_____	________

(4) There have been no returned checks, except as noted below:

	Date Originally Received	Check Amount	Date Ultimately Cured	Comments/ Explanations
1.	______	____	_____	________
2.	______	____	_____	________
3.	______	____	_____	________
4.	______	____	_____	________
5.	______	____	_____	________
6.	______	____	_____	________
7.	______	____	_____	________
8.	______	____	_____	________
9.	______	____	_____	________

(5) I acknowledge that this information is being relied upon as an inducement for a Purchaser to acquire said Note and Mortgage. I swear under penalty of perjury that the above information is true, accurate, and complete and may be relied upon in all respects.

FURTHER, Affiant(s) sayeth naught.

Date:

_______________________ _______________________

Witness Mortgagee/Affiant

_______________________

Witness

_______________________ _______________________

Witness Mortgagee/Affiant

_______________________

Witness

(State of , County of ) SS:

Before me, a Notary Public in and for said state and county, personally came , the Affiant in the above instrument, who acknowledged the execution of same to be (his, her) free and voluntary act and deed.

In testimony whereof, I have hereunto subscribed my name and affixed my notarial seal at , on this day of ,19 .

Notary Public

(Seal)

(Exp. Date)

(State of , County of ) SS:

In testimony whereof, I have hereunto subscribed my name and affixed my notarial seal at , on this day of ,19 .

Notary Public

(Seal)

(Exp. Date)