Fill and Sign the Ia Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: Parcel Identification Number: Legal Description: SUBCONTRACTOR'S NOTICE OF CLAIM OF LIEN--INDIVIDUAL (Iowa Code § 572.10) COMES NOW, ____________________________, as a party who has furnished labor or materials for the improvement of property described as ___________ _______________________________________________________________________, and would state as follows: 1. The undersigned began furnishing labor and/or materials to the above-described property on the ____ day of ___________, 20___, and completed furnishing the same on the ____ day of ______________, 20___. 2. The name and last known mailing address of the owner, agent, or trustee of the property is ______________________________________________________________. Subcontractor’s Notice of Claim of Lien Page 1 of 3 3. An accounting of the material furnished or labor performed: Material Furnished/Labor Performed Date(s) Amount Due ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. The total amount due the undersigned, allowing for all credits is $ ____________. 5. The above listed labor and/or material was furnished under agreement with principal contractor, _____________________________. On information and belief, said contractor has not filed a verified statement of account within ninety (90) days from the date of the last furnishing of labor or material. This the ______ day of _______________________, 20____. ______________________________ Signature of Subcontractor I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Verified Statement of Account are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF IOWA COUNTY OF ____________________ In _______________, on the _____________ day of ____________, 20___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing Verified Statement of Account, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed. Type of ID Produced: _________________________ Affiant __ is __ is not personally known to me Subcontractor’s Notice of Claim of Lien Page 2 of 3 _______________________________ NOTARY PUBLIC My Commission Expires: ____________________ (SEAL) Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to _____________________________________. So certified this the ______ day of ___________________, 20____. ________________________ Signature Subcontractor’s Notice of Claim of Lien Page 3 of 3