Fill and Sign the Lien Materialman 497303835 Form

CLAIM OF LIEN- MATERIALMAN - CORPORATION STATE OF GEORGIA COUNTY OF ____________________ __________________________________ , a materialman, Lienor, files this statement in writing, verified by the oath of ___________________________________ [Person Claiming Lien], who has personal knowledge of the facts herein set forth: That said, _________________________________ [Lienor] claims a lien upon the following property, situated in ___________________ County, Georgia, to wit: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ [Legal Property Description]. This lien is claimed, separately and severally, as to both the buildings and improvements thereon, and the said land. That lien claimed is for satisfaction of a claim which became due on ________________________________ for _________________________________ (i.e. building, repairing, improving, or furnishing material) in connection with the real property described above. The name of the owner of the said property is _________________________________ . __________________________________________ Claimant or Attorney for Claimant Print or Type Name: _____ ____________________ Name of Corporation: _____ __________________ Affidavit of Service Claim of Lien Page 1 of 2 State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ______________________________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the owner of the property and the contractor, as the agent of the owner, which the names and addresses are as follows: __________________________________ __________________________________ __________________________________ __________________________________ DATED this the ______ day of __________________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name Sworn to and executed in the presence of: _______________________ (Witness) Reference: 44 - 14 - 361.1 Notes: At the time of filing for record of his claim of lien, the lien claimant shall send a copy of the claim of lien by registered or certified mail or statutory overnight delivery to the owner of the property or the contractor, as the agent of the owner. Claim of Lien Page 2 of 2