Fill and Sign the Georgia Lien Form

Claim of Lien Page 1 of 3 After Recording Return to: CLAIM OF LIEN STATE OF Georgia , COUNTY OF LIEN CLAIMANT: ________________________ , a ________________________ (mechanic, contractor, subcontractor, materialman, machinist, manufacturer, registered architect, registered forester, registered land surveyor, registered professional engineer, or other person, etc.) claims a lien in the amount of $ ______________________________ (claim amount due), plus interest at the rate of ______ % from __________________ , 20 ______ , the date on which the claim came due, for construction of improvements known as (name and describe the improvement) : and the premises or real estate on which it is erected or built, which is located at ________________________ , City of __________________ , ____________ County, Georgia, the record owner of which is ____________________________________ (insert full name of record Owner) and which property is further described on Exhibit A attached to this Claim of Lien and by this reference incorporated herei n (the “Property”). The claim of lien is filed for satisfaction of a claim which became due on ____________ (last date labor, services, equipment or materials were supplied to the premises) for building, repairing, improving, and furnishing labor or material at the instance of the record o wner identified above. The claim of lien is being submitted to the Clerk of this Court with the request that it be recorded in the property records of this county established for this purpose. This claim of lien is filed within ninety (90) days after the completion of the work, the furnishing of services, and the delivery of materials which are the subject of this claim. A check in the amount of the appropriate filing fee is enclosed. NOTICE: This claim of lien expires and is void 395 days from the date of the filing of the claim of lien if no Notice of Commencement of Lien Action is filed in that time period. So filed this the ______ day of __________________ , 2 ______ Claim of Lien Page 2 of 3 Sworn to and executed in the presence of: Lien Claimant Witness Street Address Official Witness City, State and Zip Commission Expires: Telephone Number Signature Title Within two business days after the filing for record of this claim of lien, the lien claimant has sent a copy of the claim of lien by registered or certified mail or statutory overnight delivery to the record owner of the property or, if the owner’s addres s cannot be found, to the contractor, as agent of the owner, at the address provided below: (Name of record owner) (Name of prim ary contractor) (Owner’s street address) (Contractor’s street address) City, State and Zip City, State and Zip If a Notice of Commencement was properly filed with the Clerk of the Superior Court pursuant to O.C.G.A. § 44 -14 -361.5, a copy of the claim of lien also was sent by registered or certified mail or by statutory overnight delivery to the contractor at the address shown on the Notice of Commencement. NOTE TO THE PROPERTY OWNER: The owner of the property which is subject of this claim of lien has the right to contest the lien as provided in O.C.G.A. § 44 -14 -368. Claim of Lien Page 3 of 3 EXHIBIT A Legal Description of the Property