To the Principal Agent of the Mutual Assurance Society against Fire on Buildings of the State of Virginia.

TAKE NOTICE, that by virtue of authority vested in me by the Constitution of the Mutual Assurance Society aforesaid I do hereby withdraw the Insurance on all the buildings situated at Milton in the County of Albemarle and Insured by Declaration numbered 337. in the name of Bennet Hendersons Heirs and which are distinguished in the said Declaration by the letters A B. C. D. & E and I having agreeable to the said Constitution paid all claims of the Society aforesaid for the Insurance thereof I do hereby require you to issue a discharge to me as to the said Insurance; such as by the Rules and Regulations of the said Society I am entitled to receive.

In testimony that this is my act and deed I hereunto subscribe my name and affix my seal this 26th day of June 1823.

ALBEMARLE COUNTY, to wit:

The above named Thomas Jefferson this day personally appeared before me the subscriber a Justice of the Peace for the County aforesaid, and acknowledged the foregoing notice to be his own act and deed. Given under my hand this 2nd day of July 1823.

[To be executed and returned to the Office of the Society in Richmond, and accompanied by payment of all dues, or evidence of such payment.]