STATE OF GEORGIA COUNTY OF FULTON  Date of Sale:  AFFIDAVIT IN SUPPORT OF CLAIM FOR EXCESS FUNDS  Before me, the undersigned officer (Notary Public), duly authorized to administer oaths,  Appeared  on behalf of  who, after being  sworn, deposes and states under oath as follows:  1) 2)  Igive this oath of my own free will, and understand thatl am sworn to state thei truth. I am over the age of21, years, and I am authorized to swear to the matters stated herein. This Affidavit is being given for presentation to the City of Fairburn, Georgia in support of my Claim for Excess Funds received by the City as a result oft the above-referenced Tax Sale. The real property which was sold, and which is the subject oft this Claim is  described as follows: (hereinafter referred to as "Property")  Property Address: Tax Parcel ID No.:  3) The Claimant is the Owner or Lien holder identified below. COMPLETE EITHER 4 OR5(DO NOT COMPLETE BOTH) 4A) With respect to the Property, I am the.  (insert "Owner" or owner's  Representative) against whom the Sale was conducted. Imay be reached as follows:  Name: Address: Phone:  4B) Ins support of this claim I have included photo identification as the owner, or as the owner's representative Ihavei included the owner's photo identification, al Power of Attorney, a valid telephone number oft the owner and a letter stating thatl I have the 5A) With respect to the Property, I am the LIEN HOLDER'S REPRESENTATIVE (insert Lien holder" or' "Lien holder's Representative'.lmayl be reached as follows:  authority to claim the funds on behalf of the owner.  Name: Address: Phone:    5B) The lien holder is owed $_  in Excess Funds as of thet time of the sale and  included in support oft this claim is the deed creating the debt. As the lien holder's representative I have included a Power of Attorney from the lien holder which contains the title of the officer granting it, valid telephone number and al letter on the company's letterhead giving the authority to collect the excess on behalf of the lien holder. The Claimant Has / Has Not (Circle One) redeemed the Property from the Purchaser at The Claimant is the Owner or Lien holder authorized to receive the Excess Funds from There is no unsatisfied and outstanding lien, tax lien mortgage, deed to secure debt, promise, pledge, security, encumbrance, obligation, or other claim or entitlement of any type, kind or description whatsoever against the Property or the Excess Funds which is senior to or of greater legal priority than the Claimant's right to receive the Excess Funds. The Claimant has not transferred, conveyed, assigned, sold or otherwise obligated or  6) 7) 8)  the Tax Sale.  the Tax Sale pursuant to 0.C.G.A48-4-5.  9)  encumbered the Claimant's interest in the Excess Funds.  10) There is no lawsuit, garnishment, bankruptcy, or other judicial or quasi-judicial  proceeding pending either against the Claimant or on the Claimant's behalf regarding this  Claim ini the Excess Funds.  11) Deleted. 12) Deleted.  13) The Claimant understands that false swearing is punishable as a felony under the laws of the State of Georgia, and that this Affidavit is a sworn statement. 14) The Claimant understands that no legal advice is being provided by any representative of the City of Fairburn, Georgia. The Claimant has the right to seek legal advice from private  counsel.  This Affidavit is made this By:, Signature  day of  20  Printed Name On Behalf of:  Sworn to and subscribed before  Me, this Notary Public My commission expires: STATE OF GEORGIA COUNTY OF FULTON  day of.  20_    INDEMNIFICATION AND HOLD HARMLESS AGREEMENT  Before me, the undersigned officer (Notary Public), duly authorized to administer oaths,  Appeared  on behalf of  who, after being sworn,  deposes and states under oath as follows:  1) Igive these assurances of my own free will, and lunderstand thatl I am binding the Claimant and that the Claimant is sO bound. lam over the age of2 21 years, and la am authorized to swear tot the 2) This Indemnification is being given for presentation to the City of Fairburn, Georgia in support of my Claim for Excess Funds received by the City as a result of the above-referenced Tax Sale. The real property which was sold, and which is the subject of this Claim is described as follows:  matters stated herein, and to grant the assurances herein given.  (hereinafter referred to as Property")  Property Address: Tax Parcel ID No.:  3) The Claimant is the Owner or Lien holder identified in the Affidavit in Support for Excess Funds, which Affidavit has been submitted contemporaneously with the submission of this 4) As further inducement for the disbursement of the Excess Funds, the Claimant will indemnify and hold harmless the City of Fairburn, Georgia as well as its officers, officials, employees, agents, representatives, successors, and assigns, from any and all claims, whether in law, equity, or otherwise, of whatever description, which may arise from the disbursement of the Excess Funds  Indemnification.  tot the Claimant. This Affidavit is made this  day of  20_  By:  Signature  Printed Name On Behalf of: Sworn to and subscribed before  Me, this Notary Public My commission expires:  day of  20_