Fill and Sign the Massachusetts Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ____________________ Address: _____________________ City: ____________________ State: _____ Zip: __________ Phone: __________________ Fax: __________________ DISSOLUTION OF LIEN--CORPORATION (Mass. Gen. Laws Ann. ch. 254 §10) COMES NOW, _________________________________ , as a representative of _______________________________ a ________________________________ party who has furnished labor or material for the improvement of the property located at _______________________________________________________________________ , and would state as follows: 1. The undersigned is entitled to a lien against the above described property for the value of labor and or materials provided. 2. On or about the _____ day of _______________ , 20 _______ , the undersigned caused a notice of contract to be filed in the registry of deeds claiming said lien. 3. The undersigned hereby provides notice that said lien is dissolved, and no longer binding in any way upon the above described property. This the ______ day of ________________ , 20 ______ . ________________________ Signature _____ ___________________ Type or Print Name _____ ___________________ Title _____ ___________________ Corporation Attest: Secretary State of Massachusetts County _____________ On this _______ day of _________, 20 ___, before me the undersigned notary public, personally appeared ________________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were _________________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he or she signed it voluntarily for its stated purpose (as ____________ for ______________, a corporation). _____________________ Notary Public Print Name: ___________________ My commission expires: ____________________ MA ch. 254, § 10