Fill and Sign the Az Lien Form

Notice and Claim of Lien Page 1 of 2 Prepared by, recording requested by and return to: ---------------------- Above this Line for Off icial Use Only --------------------- Name: ______________________ Company: _____________________ Address: _____________________ City: ________________________ State: ______ Zip: _________ Phone: ________________________ Fax: _________________________ NOTICE AND CLAIM OF LIEN --INDIVIDUAL STATE OF ARIZONA COUNTY OF _________________ PERSONALLY came and appeared before me, the undersigned notary, the un dersigned, ____________________________________ , who upon being duly sworn, states upon oath the following: 1. The legal description of the lands and improvements to be charged with a lien is : ____________________________________ . 2. The name of the owner or repu ted owner of the property concerned, if known, is ____________________________________ ; and the name of the person by whom the Lienor was employed or to whom he furnished materials is _____________________________________ . 3. A statement of the terms, time given and conditions of the contract, if it is oral, or a copy of the contract, if it is written is ____________________________________ . 4. A statement of the Lienor's demand, after deducting just credits and offsets is $ ______________________ . 5. The date of completion of the building, structure or improvement, or any alteration or repair of such building, structure or improvem ent was the _____ day of ______ __________________ , 20 _____ . 6. The date of the Preliminary Twenty Day Notice required by Arizona Revised Statutes § 33 -992.01 was the _____ day of ________________ , 20 ______ . A copy of such Preliminary Twenty Day Notice and the proof of mailing required by Arizona Revised Statutes § 33 -992.02 is attach ed. Notice and Claim of Lien Page 2 of 2 This the _____ day of _________ , 20 ______ . ____________ _____________ Signature _____ ____________________ Print or Type Name State of Arizona Cou nty of ______________________________ The foregoing instrument was acknowledged and sworn to before me this _________ day of ______________________, ____________, by _____________________________ (person). ______________________________ NOTARY PUBLI C Print Name: ______________________ My Commission Expires: ____________________ AZ § 33.993