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) This document and accompanying materials are designed to provide authoritative information in regard to the subject matter covered in it. It is for illustration purposes only and presented with the understanding that the author and publisher are not engaged in rendering legal, accounting or other professional opinions. If legal advice or other expert assistance is required, the services of a competent professional should be sought. |
