Fill and Sign the Beginning on or About the of 20 the Undersigned Lien Form

Assignment of Lien Page 1 of 2Prepared by, recording requested by and return to:Name: ___________________Company: ___________________Address: _____________________City: __________________________State: _____Zip: _____________Phone: _____________________Fax: _______________________----------------------Above this Line for Official Use Only--------------------- ASSIGNMENT OF LIEN- INDIVIDUAL Beginning on or about the _____ of _______________, 20_____, the undersigned lien claimant, __________________________________, furnished or supplied labor, materials, or laborers to ___________________________________ for the purpose of improvements of real property at _________________________________________________________________, such that the undersigned lien claimant is entitled to a lien for the value of labor, materials, or laborers supplied. Notice is hereby given that pursuant to Section 713.19, Florida Statutes, the above- mentioned lien claimant does hereby assign his or her claim and lien to ___________________________________, who shall hereafter have all the rights and remedies under law to which the lien claimant is entitled for the purpose of filing and for the enforcement of the above-mentioned lien. This the _____ day of ____________, 20_____. ____________________________ (signature of lienor)_____________________________Type or Print Name Assignment of Lien Page 2 of 2________________________________________________________(address of lienor)STATE OF ___________ COUNTY OF _____________ Sworn to (or affirmed) and subscribed before me this _____ day of _________________, 20______ by _________________________ (name of person making statement) who is personally known to me or produced _________________________ as identification, and who did take an oath.____________________________ NOTARY PUBLICPrinted Name of Notary _________________________Commission Expires _________________________ Certificate of Service I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Actual Delivery to the person to be served. ( )Mailing a true and correct copy of same by registered or certified U.S. mail, with postage prepaid, or by overnight or second-day delivery with evidence of delivery. ( ) If service cannot be made by the above methods, by posting on the premises. ________________________Signature