FORM SLand Titles Creditor’s Statement of Debtor’s Land

1)

2) Has an interest under the following instrument: (attached)

3) Which charges or binds the interests in land of:

4) Whose address is:

5) The instrument is :

a) Currently registered against other land with the registration number

, (copy attached), or

b) Attached to this statement for registration

6) The land in which the debtor has an interest is:

(LINC number(s): )

7) And the debtor’s interest in the land is:

8) The Registrar is requested to endorse a memorandum of the instrument on the Certificate(s) of Title for this land.

9) The Land Titles Act provides that a creditor who files or continues the registration of a writ of enforcement or other instrument referred to in section 122 without reasonable cause is liable to make compensation to any person who has sustained damage as a result.

Dated this day of ,

(Signature of Creditor or Agent for Creditor0 (Print Name of Person Signing)

(Print office held if Signing for Corporation)

This information is being collected for the purposes of land titles records in accordance with the Land Titles Act. Questions about the collection of this information can be directed to the Freedom Of Information and Protection Of Privacy Co-ordinator for Alberta Registries, Research and Program Support, Box 3140, Edmonton, Alberta T5J 2G7, (780) 427-2742.

REG 3061 (2002/04)