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Fill and Sign the Affidavit of Lien Account Individual Arkansas Form

Fill and Sign the Affidavit of Lien Account Individual Arkansas Form

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Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _______________________ Company: ____________________ Address: _____________________ City: _____________________ State: ______ Zip: _________ Phone: ________________________ Fax: __________________________ Affidavit of Notice-Individual (A.C.A. § 18-44-117) COMES NOW __________________________________ , and hereby would provide notice of the following: 1. The undersigned has provided labor and/or materials for the improvement of the property located at: __________________________________ . 2. After allowing for all credits, the undersigned is due the amount of $ __________________________________ for said labor and/or materials. 3. This notice is filed within one hundred and twenty (120) days of the date labor and/or materials were provided. 4. Further, the undersigned hereby makes a sworn statement that the undersigned has complied with the notice provisions of Arkansas Code Annotated § 18-44-114 through § 18-44-116 and is attaching a copy of each notice given under Arkansas Code Annotated § 18-44-114 through § 18-44-116 to this Affidavit of Notice. Affidavit of Notice Page 1 of 2 This the _____ day of _________________ , 20 ______ . _________________________ Signature _____ ____________________ Print or Type Name STATE OF ARKANSAS COUNTY OF _________________ On this the ____ day of __________, 20__, before me, ____________________, the undersigned officer, personally appeared__________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal on this ____ day of ______, 20___. ___________________________ NOTARY PUBLIC My Commission Expires: ____________________ AR § 18-44-117(a) Affidavit of Notice Page 2 of 2

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