Fill and Sign the Ga Preliminary Notice Lien Form

Prepared by, recording requested by and return to: Name _____________________ Company ___________________ Address ________________________ City _________________________ State ____________ Zip ________________ Phone _____________________ ------------------------------------Above this line for Official Use Only ----------------------------------- PRELIMINARY NOTICE OF LIEN RIGHTS - CORPORATION STATE OF GEORGIA COUNTY OF ___________________ BE IT KNOWN THAT ___________________________________ , a mechanic, contractor, subcontractor, materialman, machinist, manufacturer, registered architect, registered forester, registered land surveyor, registered professional engineer, or other person (circle as the case may be), potential Lienor, files this Preliminary Notice of Lien Rights and upon being duly sworn, states on his or her oath the following: 1. This notice is filed with the Clerk of Superior Court of the County in which the subject real estate is located within 30 days after the Claimant: ( ) delivered materials ( ) provided any labor or services, for which a lien may be claimed. (check all that apply) 2. The name, address, and telephone number of the potential lien claimant are: _________________________________________ _________________________________________ _________________________________________ _________________________________________ 3. The name and address of the contractor or other person at whose instance the labor, services, or materials were furnished is/are: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Preliminary Notice of Lien Rights Page 1 of 4 4. The name of the owner of the real estate is: __________________________________ . 5. A description sufficient to identify the real estate against which the lien is or may be claimed is: ________________________________________ . 6. A general description of the labor, services, or materials furnished or to be furnished is as follows: ____________________________________________________________ ____________________________________________________________ The property is located in _____________________ County, Georgia and has a common address of ___________________________________________________________ . WITNESS my signature this the _____ day of ___________________ , 20 _____ . __________________________________________ Claimant or Attorney for Claimant Printed Name: _____ ________________________ Title: _____ _____________________________ Name of Corporation: _____ __________________ Attest: Secretary Preliminary Notice of Lien Rights Page 2 of 4 Affidavit of Service State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ______________________________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the contractor on the property named in the notice and to the owner of the property , which the names and addresses are as follows: __________________________________ __________________________________ __________________________________ __________________________________ DATED this the ______ day of __________________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name Sworn to and executed in the presence of: _______________________ (Witness) Sworn to (or affirmed) and subscribed before me this ____ day of __________ (month), __________ (year), by _______________________ (name of person making statement). _______ Personally Known _______ Produced Identification Type and # of ID __________________________ ____________________________ (Signature of Notary) (Seal) _____________________________ (Name of Notary Typed, Stamped or Printed) Notary Public, State of Georgia Preliminary Notice of Lien Rights Page 3 of 4 My Commission Expires: ______________ Reference: 44 - 14 - 361.3. NOTES: A party filing a preliminary notice of lien rights except a contractor shall, within seven days of filing the notice, send by registered or certified mail or statutory overnight delivery a copy of the notice to the contractor on the property named in the notice or to the owner of the property. The lien claimant may rely on the building permit issued on the property for the name of the contractor. Preliminary Notice of Lien Rights Page 4 of 4