Fill and Sign the Claim of Lien Corporation or Llc Nebraska Form

CLAIM OF LIEN- CORPORATION (NRS § 52-147) STATE OF NEBRASKA 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 _________________________________ , whose address is ___________________________________________________________________ , the lienor furnished labor, services, or materials consisting of ______________________________________________________________________________ ______________________________________________________________________________ on the following described real property in __________________________________ County, Nebraska: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (insert legal description) 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 Claim of Lien Page 1 of 2 _____ _________________________ Title _____ _________________________ Name of Corporation             Address Attest: Secretary STATE OF NEBRASKA COUNTY OF _________________ Sworn to and subscribed before me by ________________________ (name of officer or agent, title of officer or agent) of __________________________________ (name of corporation) a ______________________ (state or place of incorporation) corporation, who is personally known to me or produced ______________________ as identification, and who did ____ take an oath, this ____ day of __________________ , 20 ____ . ______________________________ Notary Public Printed Name: __________________ Title or Rank:___________________ Serial Number, if any: ____________ My Commission Expires: _____________________ Prepared by and Return to: (name and address)                         Claim of Lien Page 2 of 2