$__________________ Mortgage on Property Situated at:




Notice of Customer Required by Federal Law:


You have entered into a transaction on ____________ (month & date), _____ (year) which may result in a lien, mortgage or other security interest on your home.  You have a legal right under federal law to cancel this transaction, if you desire to do so, without any penalty, or obligation, within three business days from the above date or any later date on which all material disclosures required under the Truth in Lending Act have been given to you.


If you cancel the transaction, any lien, mortgage or other security interest on your home arising from this transaction is automatically void.  You are also entitled to receive a refund of any down payment or other consideration if you cancel.  If you decide to cancel this transaction, you may do so by notifying:

____________________________________________________________________     (Name of Creditor) at___________________________________________________________________    by mail or telegram sent no later than midnight of __________ (month & day), _____ (year).  You may also use any other form of written notice identifying the transaction if it is delivered to the above address no later than that time.  This notice may be used for that purpose by dating and signing below.


I hereby cancel this transaction.


______________________________             ______________________________

(Customer's Signature)                                    (Date)


Receipt is herewith acknowledged of the foregoing:


NOTICE, each of the undersigned customers having received two copies thereof, and one copy of the Disclosure Statements concerning the above identified transaction this ______ day of __________, _____ (year).



______________________________             ______________________________
(Signature)                                                       (Date)


(Issue two copies to customer)