Fill and Sign the Illinois Lien 497306110 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: SUBCONTRACTOR’S MECHANIC’S LIEN -- NOTICE AND CLAIM 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 ___________________, legal owner(s) of the property commonly known as ________________, County of ________________ (the “Owners”), and ___________________ as the Owner’s agent (the “Owners’ Agent”) 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: LEGAL DESCRIPTION The Property is commonly known _______________, County of _______, Permanent Real Estate Index Number __-__-__-____. 2. On information and belief, prior to _______________ Owners and Owners’ Agent entered into a contract for work to be performed at the Property by Owners’ Agent as a general contractor (the “Contract”). 3. On or about _______________, Claimant and Owners’ Agent entered into that agreement for the performance of certain work and/or the delivery of certain materials by Claimant (the “Work”) for the sum of ____________________ ($________) (the “Contract Sum”). 4. On or about _______________, Claimant completed all of the Work under the terms of and in accordance with the Contract, in that Claimant supplied all labor and materials necessary for performance of its duties under the Contract for the improvements to the Property. Subcontractor’s Mechanic’s Lien Page 1 of 2 5. All of the labor and materials furnished and delivered by Claimant were furnished to and used in connection with the improvement of the Property, and the last of such labor and materials was furnished, delivered and performed, and the work contemplated under the Contract completed, on or about _______________. 6. There is now justly due and owing the Claimant after allowing to the Owners’ Agent all credits, deductions and offsets, the sum of _______________ ($_______) 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, the Owner’s Agent 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: _________________________________ One of the Claimant's Attorneys 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 _______________________________. BY: ___________________________ Notary Public [SEAL] Subcontractor’s Mechanic’s Lien Page 2 of 2