Fill and Sign the Georgia Notice Form

Prepared by, recording requested by and return to: Name ________________________ Company __________________________ Address __________________________ City __________________________ State ______________ Zip _____________ Phone ____________________ ------------------------------------Above this line for Official Use Only ----------------------------------- NOTICE OF ACTION – INDIVIDUAL STATE OF GEORGIA COUNTY OF ____________________ Owner of Property Against Which Lien Filed: _________________________________ Deed or Other Recorded Instrument in Chain of Title of Affected Property: ___________________________________ BE IT KNOWN THAT ____________________________________ , as lien claimant, within 14 days after filing an action for the recovery of the amount of his or her lien claim within 12 months from the time the same becomes due, files this NOTICE OF ACTION with the clerk of the superior court of the county wherein the subject lien was filed, and upon being duly sworn states on his or his oath as follows: 1. A civil action was commenced in ________________ Court on _____ day of ____________ , 20 _____ involving the parties as follows: ______________________ (Plaintiff) and ________________________ (Defendant). The style and number of the action is ________________________________ . 2. The book and page number of the records of the county wherein the subject lien is recorded in the same manner in which liens specified in O.C.G.A. Section 44-14-361 are filed is ________ , ________ . 3. Pursuant to O.C.G.A. Section 44-14-361.1(a)(3), u pon filing of this notice, t he clerk of the superior court shall enter on the subject lien so referred to the book and page on which the notice is recorded and shall index such notice in the name of the then purported owner as shown by the above caption. 4. A separate lis pendens notice need not be filed with the commencement of this action. WITNESS my signature on this the _____ day of ____________________ , 20 _____ . Notice of Action Page 1 of 2 ____________________________________ Signature of Lien Claimant or Attorney of Record 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 My Commission Expires: ______________ Reference 44 - 14 - 361.1(a)(3). Notice of Action Page 2 of 2