Fill and Sign the Claim Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: __________________ Address: ____________________ City: ___________________ State: ______ Zip: _________ Phone: _________________ Fax: ___________________ CLAIM OF LIEN-CORPORATION (M.S.A.§ 570.1111) NOTICE IS HEREBY GIVEN that on the _____ day of _______________ , 20 ______ , _____________________________ , a ____________________________ corporation whose address is _______________________________________________________________________ , first provided labor or material for an improvement to: [Legal Description of Property from Notice of Commencement, including property tax identification number and address] ________________________________________________________________________ _______________________________________________________________________ , the (Owner) (Lessee) of which property is __________________________________ , whose address is ___________________________________ . The last day of providing the labor or material was the _____ day of _______________ , 20 _____ . CONTRACTORS, SUBCONTRACTORS, OR SUPPLIERS : The lien claimant's contract amount, including extras, is $ _____________ . The lien claimant has received payment thereon in the total amount of $ ___________ , and therefore claims a construction lien upon the above-described real property in the amount of $ _____________ . LABORERS : The lien claimant's hourly rate, including fringe benefits and withholdings, is $ _____________ . There is due and owing to or on behalf of the laborer the sum of $ _____________ for which the laborer claims a construction lien upon the above- described real property. This the _____ day of ______________ , 20 ______ . Claim of Lien Page 1 of 2 ________________________ Signature and Title ________________________ By Lien Claimant, Agent, or Attorney _____ ___________________ Type or Print Name _____ ___________________ ________________________ Address of Person Signing Attest: Secretary Subscribed and sworn to by _______________________ before me on the ___ day of 20____ . Signature: _________________________________ Printed Name: _____________________________ Notary public, State of Michigan, County of ____ My commission expires______________________ ___________________________ Prepared By: ___________________________ Name ___________________________ Address Proof of Service of Notice of Furnishing is required by law and must be attached. Claim of Lien Page 2 of 2