Fill and Sign the Filing Lien 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: ________________________________________________________________________ NOTICE OF FILIING CLAIM OF LIEN – INDIVIDUAL (Or. Rev. Stat. §87.039) 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 provide notice of the following: 1. A Statement of Claim of Lien regarding the above-described property was filed with the recording officer of _________________ County on the _____ day of ______________ , 20 ______ . 2. A copy of said lien claim is attached as a copy hereto. This the _____ day of ____________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Notice of Filing Claim of Lien Page 1 of 2 Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Delivery ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested. So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Filing Claim of Lien Page 2 of 2