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: _______________________ WARNING! THIS LEGAL DOCUMENT REFLECTS THAT A CONSTRUCTION LIEN HAS BEEN PLACED ON THE REAL PROPERTY LISTED HEREIN. UNLESS THE OWNER OF SUCH PROPERTY TAKES ACTION TO SHORTEN THE TIME PERIOD, THIS LIEN MAY REMAIN VALID FOR ONE YEAR FROM THE DATE OF RECORDING, AND SHALL EXPIRE AND BECOME NULL AND VOID THEREAFTER UNLESS LEGAL PROCEEDINGS HAVE BEEN COMMENCED TO FORECLOSE OR TO DISCHARGE THIS LIEN. CLAIM OF LIEN- CORPORATION or LLC (Florida Statutes Section 713.08) STATE OF FLORIDA COUNTY OF _________________ Before me, the undersigned notary public, personally appeared _________________ , who was duly sworn and says that she or he is _________________ (a representative or agent of the corporate lienor herein), _________________ (title) of _________________ (the corporate lienor herein), whose address is ______________________________________________________________________ ; and that in accordance with a contract with _________________ , lienor furnished labor, services, or materials consisting of ________________________________________________________ on the following described real property in _________________ County, Florida: (insert legal description) Claim of Lien Page 1 of 3 _______________________________________________________________________ owned by ______________________________ of a total value of $ __________________ , of which there remains unpaid $ ____________ , and furnished the first of the items on __________________ , 20 ______ , and the last of the items on __________________ , 20 ______ ; and (if the lien is claimed by one not in privity with the owner) that the lienor served her or his notice to owner on __________________ , 20 ______ , by ________________________ (method of service); and (if required) that the lienor served copies of the notice on the contractor on __________________ , 20 ______ , by ________________________ (method of service); and on the subcontractor, ________________________ , on __________________ , 20 ______ , by ________________________ (method of service). ______________________________ Signature of Lienor/Agent ______________________ Printed Name of Lienor/Agent ______________________ Title of Lienor/Agent ______________________ Name of Company ______________________ ______________________ Address Attest: Secretary Verification Pursuant to Section 713.08(2), Florida Statutes. Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true to the best of my knowledge and belief. Signature Sworn to (or affirmed) and subscribed before me this _____ day of ______________, 20____ by ________________________ (name of person making statement). NOTARY PUBLIC Claim of Lien Page 2 of 3 Print, Type or Stamp Commissioned Name of Notary Public: ______________________________ Commission Expires: __________________ Personally Known ____________ OR Produced Identification ____________ Type of Identification Produced _____________________________________ 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 Claim of Lien Page 3 of 3