Fill and Sign the Lien Statement Colorado Form

Lien Statement Prepared by, recording requested by and return to: Name: _____________________________________________ Company: __________________________________________ Address: ____________________________________________ City: _____________________________________ Zip: _________________ State: _______________________ Phone: ________________________ Fax: __________________________ Charging Lien Statement of Attorney (Colorado Revised Statute §12-5-119 State of _______________ County of _______________: The undersigned ______________ (Name of Attorney) , whose address is ________________ ____________________________________________________________ (street address, city, state, zip code) , being duly sworn hereby states that: 1. The undersigned, the lien claimant, hereby asserts a lien against the property located at ____________________________________________________________________________ (street address, city, state, zip code) , for services of attorney that were furnished by the undersigned attorney in the case of (describe) ______________________________________ ____________________________________________________________________________ . Said services consisted of (describe) _____________________________________________ ____________________________________________________________________________. 2. The owner of said property, is ______________________ (Name of Owner) , who resides at ____________________________________________________________________ __________ (street address, city, state, zip code) . 3. The amount due or owing the lien claimant is $ ______________. Attached is a copy of the Affidavit of Service of Notice of Intent to File Lien Statement, which states that the Notice was filed at least ten (10) days before the filing of this Lien Statement. The Affidavit should be filed for record with this Lien Statement pursuant to Colorado Revised Statute §12-5-119. This the _____ day of _______________, 20 _______. _________________________ Signature __________________________ Print or Type Name I, _____________________ (Name of Affiant) , do hereby swear or affirm that the matters alleged and things contained in the above Lien Statement are true and correct to the best of my knowledge, information, and belief. ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) STATE OF COLORADO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this __________________ (date) by _____________________ (Printed Name of Affiant) . ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________