Fill and Sign the Minnesota 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: ________________ STATEMENT OF LIEN -CORPORATION (M.S.A. § 514.08) COMES NOW, __________________________________ , as a party which has supplied labor, skill or material for the improvement of property and would state as follows: 1. The undersigned corporate lien claimant hereby provides notice of the intention to claim and hold a lien in the amount of $ _____________ . 2. Said amount is due and owing to the undersigned for labor performed, or for skill, material, or machinery furnished, specifically: __________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________ . 3. The name of the claimant is __________________________________ . 4. Labor, skill, or materials were provided to _______________________________ . 5. Labor, skill, or material was first provided on the _____ day of _____________ , 20 ______ . 6. Labor, skill, or material was last provided on the _____ , day of ____________ , 20 ______ . 7. The property to which the above was provided is described as _________________________________________________________________ . 8. On information and belief, the above-described property is owned by _________________________________________________________________ . 9. The undersigned lien claimant’s post office address, if any, is _______________________________________________________________________ . 10. The lien claimant hereby acknowledges that a copy of this statement must be served personally or by certified mail within the 120-day period provided by the Minnesota Code on the owner, the owner's authorized agent or the person who entered into the contract with the contractor as provided herein. 11. The notice as required by section 514.011 , subdivision 2, of the Minnesota Statutes Annotated, if any, was given. This the _____ day of _______________ , 20 _______ . __________________________ Signature _____ _____________________ Type or Print Name __________________________ _____ _____________________ Title _____ _____________________ Corporation Attest: Secretary This instrument was drafted by __________________________________ (name) of ____________________________________________________________ (address). STATE OF MINNESOTA COUNTY OF _____________ This instrument was acknowledged before me on __________________ (date) by ___________________________________ (name(s) of person(s)) as ____________________ (type of authority, e.g., officer, trustee, etc.) of ___________________________________ name of party on behalf of whom the instrument was executed). ______________________________ Notary Public (Seal, if any) Printed Name: _________________ Title (and Rank):________________ My Commission Expires: ________________ Certificate of Delivery I, _________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to __________________________________ , within 120 days of the completion of work as provided by M.S.A. § 514.08. So certified this the _____ day of ______________ , 20 ______ . ________________________ Signature