Fill and Sign the 33 993 Procedure to Perfect Lien Notice and Claim of Lien Form

Verified Statement of Lien – IndividualPage 1 of 2Prepared by: After Recording, Return to: (Full Name of Party) (Company, if applicable) (Street Address) (City, State and Zip Code) VERIFIED STATEMENT OF LIEN - INDIVIDUAL (Ala. Code § 35-11-213) State of Alabama ) ) ss. County of ) , files this statement in writing, verified by the oath of , who has personal knowledge of the facts herein set forth: 1. That said claims a lien upon the following property, situated in County, Alabama, to wit: See Legal Description Attached as Exhibit A incorporated by reference as though set forth in full Legal Description: This lien is claim, separately and severally, as to both the buildings and improvements thereon, and the said land. 2.That said lien is claim to secure an indebtedness of $ with interest, from the day of , 20 , for: (itemize and/or attach invoices) See Invoices/Statements Attached as Exhibit B incorporated by reference as though set forth in full Itemize: Verified Statement of Lien – IndividualPage 2 of 2 The name of the owner or proprietor of the said property is: (Name of Owner or Proprietor) (Street Address) (City, County, State, Zip Code) Date: (Signature Lien Claimant) (Type or Print Name) State of Alabama, CountyI, , a , in and (Name of Officer, Notary, etc.) (Position, Office or Rank of Officer) for said county in said state, hereby certify that , who (Name of Party Executing Document) being duly sworn, doth depose and say: That he has personal knowledge of the facts set forth in the foregoing statement of lien, and that the same are true and correct to the best of his knowledge and belief. (Signature of Affiant) (Type or Print Name) State of Alabama County of I, _________(name and style of officer) hereby certify that ________________ whose name is signed to the foregoing conveyance, and who is known to me, acknowledged before me on this day that, being informed of the contents of the conveyance, he executed the same voluntarily on the day the same bears date. Given under my hand this day of , 20 . Verified Statement of Lien – IndividualPage 3 of 2(Seal) ___________________________Notary Public Verified Statement of Lien – IndividualExhibit A EXHIBIT A Street Address of Property: Legal Description: Verified Statement of Lien – IndividualExhibit B EXHIBIT B Street Address of Property: Itemized Statement and Attached Invoices: