Fill and Sign the Claim of Lien by Individual Mechanics Liens Washington 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—INDIVIDUAL Assessor’s Property Tax Parcel No./Account No. _______________________________ _________________________________ , Claimant vs _________________________________ , [Name of person indebted to claimant] Notice is hereby given that the person named below claims a lien pursuant to RCW 60.04. In support of this lien the following information is submitted: 1. NAME OF LIEN CLAIMANT: _____________________________ TELEPHONE NUMBER: _____________________________ ADDRESS: _____________________________ _____________________________ 2. DATE ON WHICH THE CLAIMANT BEGAN TO PERFORM LABOR, PROVIDE PROFESSIONAL SERVICES, SUPPLY MATERIAL OR EQUIPMENT OR THE DATE ON WHICH EMPLOYEE BENEFIT CONTRIBUTIONS BECAME DUE WAS THE _____ DAY OF _______________ , 20 ______ . 3. NAME OF PERSON INDEBTED TO THE CLAIMANT: _______________________________ 4. DESCRIPTION OF THE PROPERTY AGAINST WHICH A LIEN IS CLAIMED (Street address, legal description or other information that will reasonably describe the property): Claim of Lien Page 1 of 3 ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 5. NAME OF THE OWNER OR REPUTED OWNER (If not known state "unknown"): ________________________________ 6. THE LAST DATE ON WHICH LABOR WAS PERFORMED; PROFESSIONAL SERVICES WERE FURNISHED; CONTRIBUTIONS TO AN EMPLOYEE BENEFIT PLAN WERE DUE; OR MATERIAL, OR EQUIPMENT WAS FURNISHED WAS THE _____ DAY OF _______________ , 20 _______ . 7. PRINCIPAL AMOUNT FOR WHICH THE LIEN IS CLAIMED IS: ___________________________________ . 8. IF THE CLAIMANT IS THE ASSIGNEEE OF THIS CLAIM, SO STATE HERE: _____________________________________ . ____________________________ Signature _____ ________________________ Type or Print Name _____ ________________________ Name of Claimant _____ _________________________ Street Address _____ _________________________ City, State, Zip Code _____ _________________________ Phone Number STATE OF WASHINGTON COUNTY OF __________________ , ss. ___________________________________ , being sworn, says: I am the claimant (or attorney of the claimant, or administrator, representative, or agent of the trustees of an employee benefit plan) above named; I have read or heard the foregoing claim, read and know the contents thereof, and believe the same to be true and correct and that the claim Claim of Lien Page 2 of 3 of lien is not frivolous and is made with reasonable cause, and is not clearly excessive under penalty of perjury. ______________________________ Affiant Subscribed and sworn to before me this _____ day of _____________ , 20 _________ . ______________________________ Notary Public residing at _________ Printed Name: _________________ My Commission Expires: ________________ Certificate of Delivery I, ___________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to the owner or reputed owner __________________________________ by: ( ) Personal Delivery ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested to _________________________________ . So certified this the _____ day of _______________ , 20 ______ . ________________________ Signature WA § 60.04.091 Claim of Lien Page 3 of 3