Fill and Sign the Claim Notice Form

General Form of Claim or Notice of Lien By General Contractor STATE OF ________________________________________ COUNTY OF _________________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, __________________________________________ (Contractor) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says that: 1. He is _________________________________ (e.g., president) , of ___________ _______________________________________________ (Company), a corporation organized under the laws of the State of _______________________________________ (name of state), with its principal office at _____________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) , hereinafter called Company, and makes the following statement under _______________ _________________________________ (cite state statute) for a mechanic's lien for ________________________________________________________________________ ________________________________________________________________________ __________________________________________________ (e.g., materials, labor and services furnished and performed) on the following described property now owned by _______________________________________________ (Owner) of ______________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code), said property being more particularly described as follows: (Legal Description of Property) 2. On ____________________________ (date) , Company made a written contract with Owner to ___________________________________________________________ ________________________________________________________________________ __________________________________________________ (briefly describe contract) on the real property described above. 3. Under the contract identified above, Company was to complete the work and completely perform the contract on or before _____________________________ (date) ; that Owner agreed to pay Company $______________, with the final payment to be made _______________________ (date) ; and Company did complete the work and complete performance of the contract on the ______________________________ ( date) . 4. During the period of the work required by the contract, at the special request of Owner, Company _________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ ( state what contractor did and/or describe materials furnished on and for the owner's property) , with a value of $___________________. 5. All of the materials furnished, labor performed and services rendered were used in and about _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (e.g., the erection or improvement of the building) on the property. The first of these materials, labor, and services was so furnished on __________________________ (date) , and the last of the same was so furnished on ______________________________ (date) . 6. That there is now justly due and owing to Company for the __________________ ________________________________________________________________________ ________________________________________________________________________ ______________ (e.g., furnishing of the materials, labor, and services) , after allowing all just credits, deductions, and setoffs $____________, all of which is still due and unpaid; and Company claims a lien upon the real property identified above and upon the improvements thereon for the amount of Company ’ s claim of $______________ according to the statutes that apply to this matter. In witness whereof, the above - mentioned corporation has caused this instrument to be executed in its behalf, pursuant to authority of its board of directors, by _________________________________________ (Contractor) , its ______________________________________ (e.g., President), and its corporate seal to be attached and attested by _____________________________________ (Witness), its _____________________________________ (e.g., secretary), on the _____ day of _______________________________, 20____. ____________________________________ Company By:_________________________________ Contractor , ____________________ (title) Attested to By: (Corporate seal) ___________________________________ Witness Sworn to and subscribed before me, this the ____ day of ___________________, 20____. ______________________________ NOTARY PUBLIC My Commission Expires: ______________________