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Recording Requester:

When completed, please mail to:

City, State, Zip:

CLAIM OF LIEN

NOTICE IS HEREBY GIVEN that on the day of completion or delivery date of labor and/or materials I, ("Claimant") the undersigned, in accordance with a written agreement between Company Name and Company Name to furnish and provide the scope of the Claim of Lien - including line items for all labor, materials, products, services, dates, invoices, job numbers, legal or recorded documents or any other relevant information completed delivery of the above-mentioned labor and materials to Company Name. The total value of the labor and/or materials provided. The amount owed outstanding to Company Name.

Company Name first provided labor and/or materials. The last day Company Name provided labor and/or materials.

The property to which this claim is made is:

Insert property to which this lien applies. Attach all relevant documentation to support this Claim of Lien against the property.

Total Lien Amount and Calculations:

The total of claimant's amount, including all taxes and delivery costs.

The lien claimant's amounts are derived from the following:

Insert agreed-upon invoices, contracts or other supporting documentation to support primary Claim of Lien. Insert additional documentation for subcontractors, laborers, additional work incurred because of or on behalf of the company, and documentation of all hourly rates. The lien claimant has received payments totaling Received to Date and therefore claims a lien upon the above-described real property in the amount of Total Lien Claim.

Lien Claimaint:

Company Name

City, State Postal Code

Phone: Phone Number

Lien Claimed Against:

Company Name

Address Address

City, State Zip or Postal Code

Phone: Phone Number

Proof of Service of Notice of Furnishing, if required by law, must be attached. I hereby attest that the above is true and accurate and claim a lien against the above-described property in the amount listed above.

Lien Claimant:

Job title of signator, authorized signature or signer.

Date of Agreement: