Authority for the clerk to cancel entries of other liens, mortgages, encumbrances, special claims, and like matters may be conferred by the execution by the person in whose favor such matters exist or his personal representative of a request as follows:

REQUEST TO CANCEL ENTRY

To the Clerk of the Superior Court of ________ County:

You are directed to cancel the entry registered in my favor on certificate of title No. ________, Registered Title No. ________, claiming the following lien (encumbrance or special right, as the case may be) __________________________________________________________________

This ______ day of ______________, ____.

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