Fill and Sign the Comes Now as a Representative of Form

Claim of Lien Page 1 of 2 Prepared by, recording requested by and return to: Name: ____________________ Company: _____________________ Address: _____________________ City: ________________ State: _____ Zip: __________ Phone: ________________ Fax: _________________ ----------------------Above this Line for Official Use Only--------------------- Name of Claimant: ________________________________ Name of Debtor: ________________________________ Amount of Lien: _________________ Tax Assessor’s Account Number: _________________ Situs Address of Real Property: ________________________________________________________________________ CLAIM OF LIEN – Corporation (Or. Rev. Stat. § 87.035) STATE OF OREGON COUNTY OF ____________________ COMES NOW, _______________________________, as a representative of ___________________________________ a ___________________ corporation which 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 the 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 _________________________________. Claim of Lien Page 2 of 2 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 ______. 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____________________________________ Title____________________________________ Name of Corporation Attest: Secretary Acknowledgment of Corporation STATE OF OREGON COUNTY OF ____________________ This instrument was acknowledged before me on _____ (date) by _________________________________ (name(s) of person(s)) as _________________________________ (type of authority, e.g., officer, trustee, etc.) of _________________________________ (name of party on behalf of whom instrument was executed). ______________________________ NOTARY PUBLIC Print Name: ________________ My Commission Expires: