Fill and Sign the Indiana Lien Form

Notice of Lien- Class 2 Structure -Individual (I.C.A. § 32-28-3-3(b)) COMES NOW _________________________________ of (address) ___________________________________________________________________ , and hereby provides notice of the following: 1. The undersigned has performed labor or furnished material or machinery for improvements to a Class 2 structure (as defined in IC 22-12-1-5) or for an improvement on the same real estate auxiliary to a Class 2 structure located at (legal description and street address, if any): Street Address:       Legal Description:       2. The above-mentioned property is owned by ___________________________________ of (address) ____________________________________________________________ . 3. The undersigned is entitled to a lien for the value of labor performed or material furnished in the amount of $ _______________ . 4. Labor was performed or material provided on the _____ day of _______________ , 20 ______ , being within sixty days (60) of the filing of this notice. Signature       Type or Print Name Notice of Lien – Class 2 Structure Page 1 of 3 STATE OF INDIANA ,       County, ss: Before me, the undersigned, a Notary Public in and for said County and State, personally appeared the within named       , who acknowledged the execution of the foregoing NOTICE OF LIEN – CLASS 2 STRUCTURE and who, being duly sworn, stated that the representations therein contained are true. Witness my hand and       seal this       day of       , 20       . Notary Public. Resident of       County. My Commission expires       , 20       This Instrument was prepared by:                   Signature       Print or Type Name Affirmation Statement I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document, unless required by law. Signature       Notice of Lien – Class 2 Structure Page 2 of 3 Print or Type Name Notice of Lien – Class 2 Structure Page 3 of 3