"Certification Form" - Tennessee

This "Certification Form" is a part of the paperwork released by the Tennessee Secretary of State specifically for Tennessee residents.

The latest fillable version of the document was released on June 1, 2018 and can be downloaded through the link below or found through the department's forms library.

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Download "Certification Form" - Tennessee

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Certification Form
Instructions
This Certification Form should be submitted to the Register of Deeds if no petition has been filed within
twenty (20) days following either delivery of the Notarized Affidavit – County Register of Deeds Form
contesting the lien, encumbrance or other document, or the failure of delivery for one of the reasons
outlined by T.C.A. § 66-21-123. This Certification must be verified by the Clerk and Master of the County,
confirming that no petition has been filed by the filing party, and then filed with the Register of Deeds.
This form will should be filed with the County Register of Deeds – Uncontested Lien Affidavit Form.
A blank Certification Form may be obtained by going to sos.tn.gov and entering the form name in the
search bar; or, by requesting the Certification Form from the Secretary of State by emailing
TNSOS.CORPINFO@tn.gov; or, by calling (615) 741-2286. In addition, a blank Certification Form may be
obtained in person at the Office of the Secretary of State located at 312 Rosa L. Parks Ave, FL3,
Nashville, TN 37243.
The Certification Form should be typed or hand printed in ink. Instructions for completing the
Certification Form are below.
A completed Certification Form may be submitted for filing either by mail or by hand delivery to the
County Register of Deeds in the county in which a fraudulent lien, encumbrance or any other document
was filed.
Fill in the Certification Form very carefully; mistakes may have important legal consequences. If you
have questions, consult your attorney. The Office of the Secretary of State cannot give legal advice.
Completing the Certification Form
Public Official
Name: Enter the full legal name of the affiant. Include first name, middle initial and last name.
Mailing Address: Enter the full mailing address of the affiant. Include the street address, city, state and
zip code.
Phone Number: Enter a phone number where the affiant can be reached. Include the area code.
Email Address: Enter an electronic mail address used by the affiant, if available.
Contested Document
Type of Document: Enter the type of document filed with the County Register of Deeds and which is
contested. This may be a lien, other encumbrance, or any other type of document that reasonably
constitutes a cloud on the title of a real property interest.
Office the Document Was Filed In: Enter the name of the Office in which the contested document was
filed. For example, this may be the “Davidson County Register of Deeds”.
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Certification Form
Instructions
This Certification Form should be submitted to the Register of Deeds if no petition has been filed within
twenty (20) days following either delivery of the Notarized Affidavit – County Register of Deeds Form
contesting the lien, encumbrance or other document, or the failure of delivery for one of the reasons
outlined by T.C.A. § 66-21-123. This Certification must be verified by the Clerk and Master of the County,
confirming that no petition has been filed by the filing party, and then filed with the Register of Deeds.
This form will should be filed with the County Register of Deeds – Uncontested Lien Affidavit Form.
A blank Certification Form may be obtained by going to sos.tn.gov and entering the form name in the
search bar; or, by requesting the Certification Form from the Secretary of State by emailing
TNSOS.CORPINFO@tn.gov; or, by calling (615) 741-2286. In addition, a blank Certification Form may be
obtained in person at the Office of the Secretary of State located at 312 Rosa L. Parks Ave, FL3,
Nashville, TN 37243.
The Certification Form should be typed or hand printed in ink. Instructions for completing the
Certification Form are below.
A completed Certification Form may be submitted for filing either by mail or by hand delivery to the
County Register of Deeds in the county in which a fraudulent lien, encumbrance or any other document
was filed.
Fill in the Certification Form very carefully; mistakes may have important legal consequences. If you
have questions, consult your attorney. The Office of the Secretary of State cannot give legal advice.
Completing the Certification Form
Public Official
Name: Enter the full legal name of the affiant. Include first name, middle initial and last name.
Mailing Address: Enter the full mailing address of the affiant. Include the street address, city, state and
zip code.
Phone Number: Enter a phone number where the affiant can be reached. Include the area code.
Email Address: Enter an electronic mail address used by the affiant, if available.
Contested Document
Type of Document: Enter the type of document filed with the County Register of Deeds and which is
contested. This may be a lien, other encumbrance, or any other type of document that reasonably
constitutes a cloud on the title of a real property interest.
Office the Document Was Filed In: Enter the name of the Office in which the contested document was
filed. For example, this may be the “Davidson County Register of Deeds”.
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Book and Page Number of the Document: Enter the book and page number of the document as filed
with the county register of deeds. This information can be provided to you by the County Register of
Deeds office in which the document was filed.
Signatures
The Public Official MUST sign the Certification Form before a Notary Public. The Notary Public must sign
the Certification Form, indicate the date of the notarization, list their commission expiration date and
affix their notary seal to the form. Failure to notarize the Certification Form will result in the form being
rejected.
The Certification Form MUST also be verified and signed by the Clerk and Master of the County in which
the Certification Form is to be filed. The Clerk and Master must verify that no petition has been filed in
the Chancery Court of the county relating to the Notarized Affidavit – County Register of Deeds. The
Clerk and Master must also affix their official seal to the Certification Form.
Filing Fee
There is no filing fee required.
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CERTIFICATION FORM
For Office Use Only
This document must be filed in the County Register of Deeds office where the
lien was filed. Please see the instructions to complete and submit this form.
No filing fee required
PUBLIC OFFICIAL
First:
MI:
Last:
Mailing Address:
City:
ST:
Zip:
(
)
Phone#:
Email:
CONTESTED DOCUMENT
Type of document:
Office document was filed in:
Book and Page number of the document:
Signature Date
Affiant’s (Public Official) Signature
Notary Signature
My Commission expires:
Sworn to and subscribed before me this
day of
, 20
(Rev.06/18)
All information on this form is public record.
Page 1 of 2
CERTIFICATION FORM
For Office Use Only
This document must be filed in the County Register of Deeds office where the
lien was filed. Please see the instructions to complete and submit this form.
No filing fee required
To be completed by Clerk and Master:
No petition has been filed
Clerk and Master Signature
Clerk and Master Name
Date
Seal of the Clerk
(Rev.06/18)
All information on this form is public record.
Page 2 of 2
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