Fill and Sign the Amount of Lien Form

Claim of Lien Page 1 of 2 Prepared by, recording requested by and return to: Name: ____________________Company: _____________________Address: _____________________City: ________________State: _____ Zip: __________ Phone: ________________Fax: _________________ ----------------------Above this Line for Official Use Only--------------------- Name of Claimant: ________________________________Name of Debtor: ________________________________Amount of Lien: _________________Tax Assessor’s Account Number: _________________Situs Address of Real Property: ________________________________________________________________________ CLAIM OF LIEN – Individual (Or. Rev. Stat. § 87.035) STATE OF OREGONCOUNTY OF ____________________ COMES NOW, _______________________________, as a party who has provided labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________________________________________________________________________________(legal description that includes a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition), and would state as follows: 1. The above referenced property is owned by or is reputedly owned by __________________________________. 2. That the name of the person by whom the claimant was employed or to whom the claimant furnished the materials or rented the equipment or by whom contributions are owed is _________________________________. 3. The undersigned ceased to provide labor and/or materials for the improvement of the above-described property on or about the _____ day of _________________, 20______.