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

   , 19    , by          and, (if required) that the lienor served

copies of the notice on the contractor on                                                    , 19    , by        ,

and on the subcontractor on                                            , 19    , 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)