Fill and Sign the North Carolina Lien Form

Claim of Lien Page 1 of 2Prepared by, recording requested by and return to:Name: Company: Address: City: State: Zip: Phone: Fax: ----------------------Above this Line for Official Use Only--------------------- CLAIM OF LIEN – INDIVIDUAL (N.C. Gen. Stat. § 44A-12) (1) Name and address of the person claiming the lien: ___________________ _______________________________________________________________________. (2) Name and address of the record owner of the real property claimed to be subject to the lien at the time the claim of lien is filed: __________________________________________________________________________________________________. (3) Description of the real property upon which the lien is claimed: (Street address, tax lot and block number, reference to recorded instrument, or any other description of real property is sufficient, whether or not it is specific, if it reasonably identifies what is described.) ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________________________________________________________________________________. Claim of Lien Page 2 of 2 (4) Name and address of the person with whom the claimant contracted for the furnishing of labor or materials: ____________________________________________________________________________________________________________________. (5) Date upon which labor or materials were first furnished upon said property by the claimant: _________________________________________________________. (5a) Date upon which labor or materials were last furnished upon said property by the claimant: ________________________________________________________. (6) General description of the labor performed or materials furnished and the amount claimed therefor: _________________________________________________ ______________________________________________________________________. ________________________________Lien ClaimantFiled this ____ day of ______, _____ Acknowledgment of Individual STATE OF NORTH CAROLINACOUNTY OF _____________________ I, a Notary Public, do hereby certify that _________________________________ (here give the name of the grantor or maker) personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and (where an official seal is required by law) official sealThis the ___________________ day of ___________________ (year). (Official seal.) ______________________________Notary Public Printed Name: _________________ My Commission Expires: _____________________