Fill and Sign the Affidavit of Liencorporationperson Other Than Original Form

Affidavit of LienPage 1 of 4 Prepared by, recording requested by and return to: Name: Company: Address: City: State: Zip: Phone: Fax: ----------------------Above this Line for Official Use Only--------------------- 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—CORPORATION—PERSON OTHER THAN ORIGINAL CONTRACTOR- CORPORATION 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 LienPage 2 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 LienPage 3 of 4 F. Claimant was employed to furnish the same by ___________________________, whose address is: _________________________________________________________ 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. If 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 Corporation By: Print Name Affidavit of LienPage 4 of 4 Its: Attest: Title Corporate Secretary Print Name STATE OF TEXAS COUNTY OF ________________ This instrument was acknowledged before me on _____(date)_____ by ________(name of officer)_______, _________(title of officer)_________ of (name of corporation acknowledging) a (state of incorporation) corporation, on behalf of said corporation. Notary Public Printed Name My Commission Expires: 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