CLAIM OF LIEN
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
_____________________, _______(year) , by ___________________________and, (if required)
that the lienor served copies of the notice on the contractor on ______________________,
______ (year), by__________________________, and on the subcontractor ________________
______________________ on_________________, _______ (year), by ____________________.
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.
Affiant _____Known _____Unknown
ID Produced ________________________