"This is to certify that the total outstanding balance of all obligations, the payment of which is secured by that certain instrument executed by____________, dated__________, recorded in book _________ at page ____ in the office of the Register of Deeds of ______ County, North Carolina, is $________, of which amount $________ represents principal.
No future advances will be made under the aforesaid instrument, except such expense as it may become necessary to advance to preserve the security now held.
This __________ day of ______________________ , 19_________.
____________________________
(Signature and Acknowledgment)"
N.C. Gen. Stat. § 45-72