Fill and Sign the Claim of Lien by Corporation or Llc North Carolina 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 (N.C. Gen. Stat. § 44A-12) (1) Name and address of the person claiming the lien: ___________________ _______________________________________________________________________. (2) Name and address of the record owner of the real property claimed to be subject to the lien at the time the claim of lien is filed: ___________________________ _______________________________________________________________________. (3) Description of the real property upon which the lien is claimed: (Street address, tax lot and block number, reference to recorded instrument, or any other description of real property is sufficient, whether or not it is specific, if it reasonably identifies what is described.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. Claim of Lien Page 1 of 3 (4) Name and address of the person with whom the claimant contracted for the furnishing of labor or materials: _____________________________________________ _______________________________________________________________________. (5) Date upon which labor or materials were first furnished upon said property by the claimant: _________________________________________________________. (5a) Date upon which labor or materials were last furnished upon said property by the claimant: ________________________________________________________. (6) General description of the labor performed or materials furnished and the amount claimed therefor: _________________________________________________ ______________________________________________________________________. ________________________________ Lien Claimant Filed this ____ day of ______, _____ Acknowledgment of Corporation STATE OF NORTH CAROLINA COUNTY OF _____________________ I, ____________________________________ (Name of officer taking acknowledgment), ________________________________________ (Official title of officer taking acknowledgment) certify that ____________________________________ (Name of attesting official) personally came before me this day and acknowledged that he/she is ____________________________________ (Title of attesting official) of ____________________________________, a corporation, and that by authority duly given and as the act of the corporation, the foregoing instrument was signed in its name by its __________________, (Title of Official), sealed with its corporate seal, and attested by himself (or herself) as its ____________________________________ (Title of attesting official). Witness my hand and official seal, this the ____________ day of __________________, (Month) __________________ (Year) ______________________________ Notary Public Claim of Lien Page 2 of 3 Printed Name: _________________ My Commission Expires: _____________________ Claim of Lien Page 3 of 3