Fill and Sign the Lien Notice Individual Form

Lien Notice – Individual Page 1 of 3 Prepared by: Return to: State of MississippiCounty of ________________________ Judicial District LIEN NOTICE- INDIVIDUAL Name and Address of Owner:Name and Address of Lien Claimant: NOTICE is hereby given that __________________________________, does hereby claim a lien on the following property situated in ____________________ County, Mississippi, to-wit:(See Exhibit A attached hereto and incorporated herein as though set forth in full) Indexing Instructions: The aforesaid lien is in the amount of $________________, which is the unpaid balance for goods, materials and services furnished in the construction of the improvements on the above described real property, at the request of the owner of said property, _________________________________. Lien Notice – Individual Page 2 of 3 Suit has/ has not been filed at ________________________________ . The Contract has/ has not been filed or recorded at ________________________________ . The undersigned claims a contractors and materialmens lien under the provision of Section 85-7-131, Mississippi Code of 1972, as amended.WITNESS my signature this the _____ day of _______________, 20______. BY: ____________________________________________________________________________Type or Print Name STATE OF MISSISSIPPICOUNTY OF ________________SWORN TO AND SUBSCRIBED before me on this _____ day of ______________, 20______. __________________________________________NOTARY PUBLIC MY COMMISSION EXPIRES: _______________ Lien Notice – Individual Page 3 of 3 EXHIBIT A