COLLATERAL MORTGAGE
SECTION 255 AFFIDAVIT

STATE OF _____________ }
COUNTY OF ___________ } ss.

___________________________ , being duly sworn, deposes and says:

1. That he resides at __________________________, and that he is an officer, to wit ______________ , of _____________________________ having its principal office at ______________________.

2. That said ___________________________ is the owner and holder of a mortgage made by ____________________ to ______________________ to secure the payment of the principal sum of $ _______________ dated ____________ and recorded in the Office
of the Register/Clerk of the county of _____________ in Reel/Liber _________ of Mortgages at page __________ covering premises ____________________________, which mortgage there is now unpaid the sum of $________________ , the mortgage tax thereon having been paid under Serial No. _____________ .

3. That as further and additional security for the payment of the said indebtedness mentioned in and secured by the above mentioned mortgage, __________________ executed and delivered to _________________ a certain indenture of mortgage, dated , covering premises known as _________________________ , which said collateral mortgage is herewith offered for record in the Office of the Register/Clerk of the County of ___________ .

4. That the said additional indenture is given for the purpose of further securing the same principal indebtedness which is or under any contingency may be secured by the above mentioned primary mortgage and that such additional and collateral mortgage does not create or secure any new or further indebtedness or obligation other than the principal indebtedness or obligation secured by or which under any contingency may be secured by the said primary mortgage.

Wherefore, deponent respectfully requests that such additional mortgage may be declared exempt from taxation pursuant to Section 255 of Article XI of the Tax Law of the State of New York.

________________________

Sworn to before me this
____ day of ______, 19 ___

_______________________

[Notary]