Fill and Sign the Missouri 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: ________________ LIEN CLAIM--INDIVIDUAL (M.A.S. § 429.080) COMES NOW, __________________________________ , a party providing labor, material, or machinery for the improvement of the property described as: ________________________________________________________________________ _______________________________________________________________________ , and would state as follows: 1. The owner of the above mentioned property is __________________________________ . 2. The contractor responsible for said improvements is _____________________________________ . 3. After accounting for all credits given, the undersigned is entitled to the sum of $ ______________ for the following labor, material, or machinery provided: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 4. Labor, material, or machinery began being provided on the _____ day of ______________ , 20 ______ , said date being within six (6) months after the indebtedness accrued. This the _____ day of ______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name Lien Claim Page 1 of 2 I, _________________________________ , do hereby swear or affirm that the matters and things alleged in the foregoing Lien Claim are true and correct to the best of my knowledge. This the _____ day of _______________ , 20 ______ . ______________________________ Affiant STATE OF MISSOURI COUNTY OF ______________ On this _______ day of _____________ , 20 _____ , before me personally appeared ____________________________________ , to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed my official seal in the county and state aforesaid, the day and year first above written. ______________________________ Notary Public My commission expires: _______________ MO § 429.080 Lien Claim Page 2 of 2