Affidavit of Lien

Affidavit of Lien — Corporation — Person Other Than Original Contractor

NOTICE: THIS IS NOT A LIEN. THIS IS ONLY AN AFFIDAVIT CLAIMING A LIEN.

County of )

State of Texas )

A. Claimant:

Mailing Address:

Physical Address:

claims a mechanics' or materialman’s lien on the real property and improvement in the City of , County of , Texas, located at .

B. The legal description of the property is:

C. The following person(s) has an ownership interest in the property or are reputed to have a property interest in said Property:

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:

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

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 , .

STATE OF TEXAS

COUNTY OF

This instrument was acknowledged before me on by , of a corporation, on behalf of said corporation.

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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.

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Signature