Fill and Sign the Lien 497295529 Form

STATEMENT OF LIEN State of Alabama County of ___________________________________ ___________________________________ files this statement in writing, verified by the oath of ___________________________________ , who has personal knowledge of the facts herein set forth: That said _____________________________________ claims a lien upon the following property, situated in ___________________________________ county, Alabama, to wit: ____________________________________ . This lien is claimed, separately and severally, as to both the buildings and improvements thereon, and the said land. That said lien is claimed to secure an indebtedness of ______________________ dollars with interest, from the _____ day of _______________ , 20 _____ , for ____________________________________ . The name of the owner or proprietor of the said property is _________________________________ . _________________________ Signature _____ _____________________ Print or Type Name State of Alabama County of I, ______________________ (name and style of officer) hereby certify that __________________________ whose name is signed to the foregoing conveyance, and who is known to me, acknowledged before me on this day that, being informed of the contents of the conveyance, he executed the same voluntarily on the day the same bears date. Given under my hand this day of , 20 . (Seal) ____________________________ Notary Public AL-02023 Statement of Lien Page 1 of 1