Fill and Sign the Az Liens Form

Notice and Claim of Lien Page 1 of 2 Prepared by, recording requested by and return to: ---------------------- Above this Line for Of ficial Use Only --------------------- Name: ___________________ Company: _________________ Address: ______________________ City: __________________ State: ______ Zip: ________ Phone: ______________________ Fax: ______________________ NOTICE AND CLAIM OF LIEN — CORPORATION , LLC, etc. STATE OF ARIZONA COUNTY OF ___________________ PERSONALLY came and appeared before me , the undersigned notary, the undersigned, ____________________________________ , who upon being duly sworn, states upon oath the following: 1. That he/she is the _______________________________________ of ___________________________________ , a corporation and makes this affida vit in his or her capacity as such officer. 2. The legal description of the lands and improvements to be charged with a lien is : _____________________________________ . 3. The name of the owner or reputed owner of the property concerned, if known, is ____________________________________ ; and the nam e of the person by whom the Lienor was employed or to whom he furnished materials is ___________________________________ . 4. 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 _____________________________________ . 5. A statement of the Lienor's demand, after deducting just credits and offsets is $ ____________________ . 6. The date of completion of the building, structure or improvement, or any alteration or repair of such building, structure or improvement was the ______ day of ____________________ , 20 _____ . Notice and Claim of Lien Page 2 of 2 7 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 attached. This the _____ day of __________________ , 20 ______ . ______________________________ Name of Co mpany By: ____________ _____ ___ ____ __ ___ _____ __ Signature Title ______________________________ Type or Print Name Attest: Secretary State of Arizona County of ______________________________ The foregoing instrument was acknowledged and sworn to before me this _______________(date) by ______________________________ (name of officer or agent, title or officer or agent) of ______________________________ (name of corporation acknowledging) a _________________________(state or place of incorporation) corporation, on behalf of the corporation. ____________________________ __ NOTARY PUBLIC Print Name: _______________________ My Commission Expires: _____________________ AZ § 33 -993