Claim of lien
Claim of lien form
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 subscribed to the within instrument and acknowledged to me
the person(s) whose name(s) is/are 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.
Signed
Affiant Known Unknown
ID Produced
(Seal)
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