CLAIM OF LIEN FORM

STATE OF ________________

COUNTY _________________

BEFORE ME, the undersigned Notary Public, personally appeared _______________________________ who duly sworn says that he is (the lienor herein) (the agent of the lienor herein) whose address is ___________________________________________ and that in accordance with a contract with lienor furnished labor, services or materials consisting of:

on the following described real property in _________________________ County, State of _________________________, described as __________________________________________________ and owned by ___________________________________ of a total value of dollars ($_________________________) of which there remains unpaid $_________________________, and furnished the first of the items on _________________________, 20_______, by _________________________ and, (if required) that the lienor served copies of the notice on the contractor on _________________________, 20_______, by_________________________, and on the subcontractor on _________________________, 20_______, by________________________________.

Lienor

By:

Agent

On____________________before me,______________________, personally appeared ______________________________________________, personally known to me (or proved
to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

WITNESS my hand and official seal.

Signature______________________________

Affiant _____Known _____Unknown

ID Produced______________________

(Seal)
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