Fill and Sign the Illinois Lien 497306092 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name:       Company:       Address:       City:       State:       Zip:       Phone:       Fax:       GENERAL CONTRACTOR'S MECHANIC’S LIEN NOTICE AND CLAIM - INDIVIDUAL STATE OF ILLINOIS ) ) SS. COUNTY OF       ) The undersigned Claimant,       , of       , County of       (the “Claimant”), hereby claims a mechanics lien pursuant to the Mechanics Lien Act of the State of Illinois against       regarding the property commonly known as             County of       (the “Owner(s)"), and states as follows: 1. Owner(s) now holds title to that certain real property in the County       , State of Illinois (the “Property”), to wit: Insert Legal Description or state "See attached Exhibit "A" and attach as exhibit" The Property is commonly known as       , County of       . 2. On or about       Claimant and Owner(s) entered into that certain agreement (the “Contract”) for the performance of certain work and/or the delivery of certain materials by Claimant (the “Work”) for the sum of :       ($       ) (the “Contract Sum”). General Contractor’s Mechanic’s Lien Page 1 of 2 4. On or about       , Claimant completed all of the Work under the terms of and in accordance with the Contract, in that Claimant supplied all labor and materials necessary for performance of its duties under the Contract for the improvements to the Property. 5. All of the labor and materials furnished and delivered by Claimant were furnished to and used in connection with the improvement of the Property, and the last of such labor and materials was furnished, delivered and performed, and the work contemplated under the Contract completed, on or about       . 6. There is now justly due and owing the Claimant after allowing to the Owner(s) all credits, deductions and offsets, the sum of $       plus interest at the rate specified in the Illinois Mechanics Lien Act. 7. Claimant now claims a lien on the above-described Property, and on all of the improvements thereon, against the Owner(s) and all persons interested therein for       plus interest at the rate specified in the Illinois Mechanics Lien Act, as well as court costs and attorney fees. CLAIMANT NAME BY: ______________________________ Claimant or Attorney Type or Print Name _____ _______________ STATE OF ILLINOIS ) ) SS. COUNTY OF _______ CERTIFICATION The Affiant,       , being first duly sworn, on oath deposes and says he is one of the principals of       (“Claimant”); that the Affiant has read the foregoing Notice and Claim for Lien and knows the contents thereof; and that statements therein contained are true to the best of Affiant’s knowledge. BY: ____________________________________ CLAIMANT Subscribed and Sworn to Before me this       . ____________________________________ Notary Public [SEAL] General Contractor’s Mechanic’s Lien Page 2 of 2