Fill and Sign the Affidavit of Claim of Lien for Person Other Than Original Contractor Mechanics Liens Individual Texas Form

Prepared by, recording requested by and return to:       ----------------------Above this Line for Official Use Only---------------------Name:       Company:       Address:       City:       State:       Zip:       Phone:       Fax:       NOTICE OF CONFIDENTIALITY RIGHTS: IF YOU ARE A NATURAL PERSON, YOU MAY REMOVE OR STRIKE ANY OF THE FOLLOWING INFORMATION FROM THIS INSTRUMENT BEFORE IT IS FILED FOR RECORD IN THE PUBLIC RECORDS: YOUR SOCIAL SECURITY NUMBER OR YOUR DRIVER’S LICENSE NUMBER. AFFIDAVIT OF LIEN—INDIVIDUAL—PERSON OTHER THAN ORIGINAL CONTRACTOR - INDIVIDUAL NOTICE: THIS IS NOT A LIEN. THIS IS ONLY AN AFFIDAVIT CLAIMING A LIEN. County of ______________ ) ) State of Texas ) A. Claimant:       Mailing Address:       (street, city, state, and zip code) Physical Address:       (street, city, state, and zip code) claims a mechanics' or materialman’s lien on the real property and improvement in the City of _____________ , County of _____________ , Texas , located at _____________________________________________________________ . Affidavit of Lien Page 1 of 4 B. The legal description of the property is: [Insert legal description or attach as Exhibit A]                         C. The following person(s) has an ownership interest in the property or are reputed to have a property interest in said Property:             (Name) (Last Known Address)             (Name) (Last Known Address)             (Name) (Last Known Address) D. Said claim is for the sum of $ ____________ , plus interest at the contract rate or the legal rate, whichever is higher from ________________ , which is due and unpaid to claimant (after deducting any just credits and offsets, if any) for labor, services, equipment and/or materials furnished by claimant and consisting of:                         . See attached contracts, invoices or other supporting documents incorporated as: Exhibit Description                                     E. The following is a record of the month in which the work was done and/or materials furnished for which payment is sought: Month/Day/Year Material, labor or services furnished Affidavit of Lien Page 2 of 4                                                 F. Claimant was employed to furnish the same by ___________________________ , whose address is _________________________________________________________ and furnished the same to ___________________________________________ , whose address is ______________________________________________________________ . G. The following is a record of the date each notice of the claim was sent to the owner and the method by which the notice was sent: Date Method by which claimant sent notice                                                             H. I f this claim remains unpaid, the owner may be personally liable and the owner's property may be subjected to a lien unless: (1) The owner withholds payments from the contractor for payment of the claim; or (2) The claim is otherwise paid or settled. Dated and sworn to this _____ day of _______________ , 20 ____ at _____________ , _______ . Signature and Acknowledgment of Individual Claimant             Doing Business as Affidavit of Lien Page 3 of 4 STATE OF TEXAS COUNTY OF _____________ This instrument was acknowledged before me on _____(date)_____ by (name or names of person or persons acknowledging) . Notary Public My Commission Expires:             Printed Name Certificate of Delivery I, _____________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to _____________________________________________ by: Hand Delivery Mailing a true and correct copy of same by Certified or Registered U.S. Mail, postage prepaid, to ____________________________________________ , at his usual place of business located at ___________________________________________ . So certified this the _____ day of _________________ , 20 ____ . Signature TX Code § 53.052 Affidavit of Lien Page 4 of 4