Fill and Sign the Account and Affidavit of Accounts Claiming Materialman or Labor Lien for Architect by Individual Arkansas Form

STATE OF ARKANSAS ) ) ss. COUNTY OF __________ ) ACCOUNT AND AFFIDAVIT OF ACCOUNTS MATERIALMAN OR LABOR LIENS- INDIVIDUAL Comes now ______________________________ , and states on oath: 1. That ______________________________ sold or delivered to ______________________________________ services as an architect and consultant for the design of an office building known as ________________________ and located at __________________________ , ___________ , ________________ County, Arkansas. The statement of account is attached hereto as Exhibit “A” and incorporated herein. The finally delivery of services has occurred within the last 120 days. 2. The attached statement of account is true and correct, and that there is now duly owing to ________________________ , after all credits, the sum of $ ____________ . 3. That said services will furnished for and used in the design for the construction of an office building located ________________________ , ____________ , ___________ County, Arkansas which was constructed or to be constructed on the following described real property in _____________ County, Arkansas, to wit: SEE ATTACHED SURVEYOR’S DESCRIPTION. 4. That __________________ , claims a lien on the property described aforesaid the secure the sum of $ ______________ plus all accrued interest, fees and costs; and that more than ten (10) days caused notice to be served, copy of which is attached hereto. Account and Affidavit of Accounts Page 1 of 2 Respectfully Submitted, ______________________________ Signature       Print or Type Name VERIFICATION STATE OF ARKANSAS COUNTY OF _________________ On this the ____ day of __________, 20__, before me, ____________________, Notary Public (or before any officer within this State or without the State now qualified under existing law to take acknowledgments) , personally appeared__________________________, known to me personally well known (or satisfactorily proven to be such person), who stated and acknowledged that [he, she or they] had so signed, executed and delivered said foregoing instrument for the consideration, uses and purposes therein mentioned and set forth. In testimony whereof, I hereunto set my hand and official seal on this ____ day of ______, 20___. ___________________________ NOTARY PUBLIC My Commission Expires: ____________________ Account and Affidavit of Accounts Page 2 of 2