Fill and Sign the Account Affidavit Form

After Recording Return to: _________________________ _________________________ _________________________ _________________________ ) ) ) ) ) ) ) ) -------- Above This Line Reserved For Official Use Only---------------- ACCOUNT AND AFFIDAVIT OF ACCOUNT MATERIALMAN'S OR LABORER'S LIEN ___________________________________ , a corporation, by ________________________________ , the ____________________________________ of said corporation, states on oath; 1. That ______________________________________ sold and delivered to __________________________________ the materials (or furnished the labor] listed and set forth in the statement of account which is attached hereto as Exhibit A and incorporated herein. The final delivery of such materials [or furnishing of said labor] occurred within the last 120 days. 2. That the attached statement of account is true and correct, and that there is now due and owing to ______________________________________ after allowing all credits, the sum of $ ___________________ . 3. That said materials [or labor] were furnished for and used in the construction of ____________________________________ which was constructed on the following legally described property in ___________________________________ County, Arkansas: ____________________________________ . 4. That ____________________________________ claims a lien on the property described aforesaid to secure said sum of $ ____________________ and that more than 10 days ago caused notice to be served, copy of which is attached hereto. Account and Affidavit of Account Page 1 of 3 By: _________________________________ Signature _____ _____________________________ Print or Type Name Attest: __________________________________ __________________________________ STATE OF ARKANSAS COUNTY OF _________________ On this the ____ day of ______________, 20__, before me, _______________________, the undersigned officer, personally appeared _______________________, who acknowledged himself to be the _______________ of _______________________, a____________________ corporation, and that he, being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as ____________________. In witness whereof I hereunto set my hand and official seal on this ____ day of ______, 20___. ___________________________ NOTARY PUBLIC My Commission Expires: ____________________ STATE OF ARKANSAS COUNTY OF _________________ On this the ____ day of ______________, 20__, before me, _______________________, the undersigned officer, personally appeared _______________________, who acknowledged himself to be the _______________ of _______________________, a____________________ corporation, and that he, being Account and Affidavit of Account Page 2 of 3 authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as ____________________. In witness whereof I hereunto set my hand and official seal on this ____ day of ______, 20___. ___________________________ NOTARY PUBLIC My Commission Expires: ____________________ Account and Affidavit of Account Page 3 of 3