Fill and Sign the Claim of Lien by Individual Oregon Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: _____________________ Address: _____________________ City: ________________ State: _____ Zip: __________ Phone: ________________ Fax: _________________ Name of Claimant: ________________________________ Name of Debtor: ________________________________ Amount of Lien: _________________ Tax Assessor’s Account Number: _________________ Situs Address of Real Property: ________________________________________________________________________ CLAIM OF LIEN – Individual (Or. Rev. Stat. § 87.035) STATE OF OREGON COUNTY OF ____________________ COMES NOW, _______________________________ , as a party who has provided labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ ________________________________________________________________________ (legal description that includes a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition), and would state as follows: 1. The above referenced property is owned by or is reputedly owned by __________________________________ . 2. That t he name of the person by whom the claimant was employed or to whom the claimant furnished the materials or rented the equipment or by whom contributions are owed is _________________________________ . 3. The undersigned ceased to provide labor and/or materials for the improvement of the above-described property on or about the _____ day of _________________ , 20 ______ . Claim of Lien Page 1 of 2 4. After deducting all just credits and offsets, the undersigned is entitled to the sum of $ _____________________ for said labor and/or materials. I certify that the foregoing statement of claim with all attachments are true, complete, and correct to the best of my knowledge and belief. This the _____ day of __________________ , 20 ______ . ____________________________________ Signature _____ _______________________________ Type or Print Name Acknowledgment of Individual STATE OF OREGON COUNTY OF _________________ This instrument was acknowledged before me on _______________________ (date) by __________________________________________ (name(s) of person(s)). ______________________________ NOTARY PUBLIC Print Name: ___________________ My Commission Expires: ____________________ Claim of Lien Page 2 of 2