Fill and Sign the Lien Claimants Verified Statement Individual Form

VERIFIED STATEMENT OF ACCOUNT--CORPORATION (M.S.A. § 514.07) COMES NOW, __________________________________, as a representative of __________________________________ a _________________________________ corporation entitled to a lien for labor, skill, or materials furnished for the improvement of the property at _______________________________________________________________________, and would state as follows:1.On or about the _____ day of ______________ , 20_______, the undersigned corporate lien claimant received a request from the property owner for an itemized and verified account of the undersigned’s lien as well as the amount of the lien and the lien claimant’s name and address.2.Pursuant to that request, the lien claimant would respond as follows:(A)Date Material/Labor Provided Cost________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (B) The estimated total amount of the lien claim is $_____________. (C) The corporation’s full name and address for purposes of service of process is ________________________________________________________________________ _______________________________________________________________________.3.Further, pursuant to Minnesota statute, the corporate lien holder would hereby give notice that should the lien amount remain unpaid, the lien holder may commence a legal action to enforce his/her lien within ten (10) days of the furnishing of this notice. This the _____ day of ______________ , 20______. ______________________________Signature ______________________________ Type or Print Name______________________________ Title______________________________Corporation STATE OF MINNESOTA COUNTY OF ________________ This instrument was acknowledged before me ________________ (date) by ___________________________________ (name(s) of person(s)) as ___________________________________ (type of authority, e.g., officer, trustee, etc.) of _____________________________________ name of party on behalf of whom the instrument was executed). __________________________Signature (Notary Public) (Seal, if any) __________________________ __________________________ Title (and Rank) My commission expires: ________________ MN § 514.07