Fill and Sign the Lien Claim Corporation or Llc Missouri Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: ___________________ Address: ___________________ City: ___________________ State: ______ Zip: __________ Phone: ______________ Fax: ________________ LIEN CLAIM--CORPORATION (M.A.S. § 429.080) COMES NOW, _________________________________ , a party providing labor, material, or machinery for the improvement of the property described as: ________________________________________________________________________ _______________________________________________________________________ , and would state as follows: 1. The owner of the above mentioned property is ________________________________ . 2. The contractor responsible for said improvements is _______________________________ . 3. After accounting for all credits given, the undersigned is entitled to the sum of $ ___________________ for the following labor, material, or machinery provided: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 4. Labor, material, or machinery began being provided on the _____ day of _______________ , 20 ______ , said date being within six (6) months after the indebtedness accrued. This the _____ day of ____________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Lien Claim Page 1 of 2 _____ _________________________ Title _____ _________________________ Corporation Attest: Secretary I, _____________________________________ , do hereby swear or affirm that the matters and things alleged in the foregoing Lien Claim are true and correct to the best of my knowledge. This the _____ day of _______________ , 20 ______ . ______________________________ Affiant STATE OF MISSOURI COUNTY OF ________________ On this _____ day of ______________ , 20 _______ , before me personally appeared __________________________________ , to me personally known who, being by me duly sworn, did say that he/she is the __________________________________ of _________________________________ , a Missouri corporation, and that the seal affixed to the foregoing instrument is the corporate seal of said corporation, and that said instrument was signed and sealed on behalf of said corporation by authority of its board of directors; and said _____________________________________ acknowledged said instrument to be the free act and deed of said corporation. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal in the county and state aforesaid, the day and year first above written. ______________________________ Notary Public My commission expires: _________________ MO § 429.080 Lien Claim Page 2 of 2