Fill and Sign the Michigan Claim Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: __________________ Company: __________________ Address: ___________________ City: ____________________ State: _____ Zip: __________ Phone: ________________ Fax: _________________ CLAIM OF LIEN-INDIVIDUAL (M.S.A.§ 570.1111) NOTICE IS HEREBY GIVEN that on the _____ day of _______________ , 20 _____ , _________________________________ (Person Claiming Lien) whose address is ___________________________________ , first provided labor or material for an improvement to: [Legal Description of Property from Notice of Commencement, including property tax identification number and address] _________________________________________________________________ ________________________________________________________________ , the (Owner) (Lessee) of which property is ___________________________________ , whose address is ___________________________________ . The last day of providing the labor or material was the _____ day of _______________ , 20 _____ . CONTRACTORS, SUBCONTRACTORS, OR SUPPLIERS : The lien claimant's contract amount, including extras, is $ ___________ . The lien claimant has received payment thereon in the total amount of $ __________ , and therefore claims a construction lien upon the above-described real property in the amount of $ ____________ . LABORERS : The lien claimant's hourly rate, including fringe benefits and withholdings, is $ _____________ . There is due and owing to or on behalf of the laborer the sum of $ _____________ for which the laborer claims a construction lien upon the above- described real property. This the _____ day of _____________ , 20 ______ . ________________________ Lien Claimant Claim of Lien Page 1 of 2 ________________________ By Lien Claimant, Agent, or Attorney _____ ___________________ Type or Print Name _____ ___________________ ________________________ Address of Person Signing Subscribed and sworn to by _______________________ before me on the ___ day of 20____ . Signature: _________________________________ Printed Name: _____________________________ Notary public, State of Michigan, County of ____ My commission expires______________________ ___________________________ Prepared By: ___________________________ Name ___________________________ Address Proof of Service of Notice of Furnishing is required by law and must be attached. Claim of Lien Page 2 of 2