RECORDING REQUESTED BY:
AND WHEN RECORDED MAIL TO:
(City, State & Zip)
SPACE ABOVE THIS LINE FOR RECORDER'S USE
The undersigned __________________________, claimant, claims a Mechanic's Lien upon the following described real property: __________________________________
_____________________________________________________________________. The sum of __________________ Dollars ($__________), together with interest there upon at the highest legal rate per annum from ___________________________ is due claimant (after deducting all just credits and offsets) for the following work, equipment, and material furnished by claimant: ___________________________________________________________.
Claimant furnished the work and materials at the request of, or under contract with: _____________________________________________________________________.
The owners and reputed owners of the property is/are: __________________________ ____________________________________________________________________.
Firm Name: _______________________ By: _________________________
I, the undersigned, say: I am the claimant or agent or the claimant of the foregoing Mechanic's Lien. I have read said claim or Mechanic's Lien and know the contents thereof. The same is true of my own knowledge and I am authorized to execute this Claim of Lien.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on ____________________________ (month & day), __________ (year), at _________________________ (City), ____________________________ (State).