Fill and Sign the Notice is Hereby Given that as a Representative of a Corporation Does Hereby Claim a Lien on the Following Property Situated in Form

Prepared by: Return to:                                     State of Mississippi County of ____________ ____________ Judicial District LIEN NOTICE- CORPORATION Name and Address of Owner: Name and Address of Lien Claimant:                                     NOTICE is hereby given that __________________________________ , as a representative of _________________________________ a ________________________ corporation, does hereby claim a lien on the following property situated in ____________________ County, Mississippi, to-wit: (See Exhibit A attached hereto and incorporated herein as though set forth in full) Indexing Instructions:       The aforesaid lien is in the amount of $ ________________ , which is the unpaid balance for goods, materials and services furnished in the construction of the improvements Lien Notice – Corporation Page 1 of 3 on the above described real property, at the request of the owner of said property, _________________________________ . Suit has/ has not been fled at ________________________________ . The Contract has/ has not been fled or recorded at ________________________________ . The undersigned claims a contractors and materialmens lien under the provision of Section 85-7-131, Mississippi Code of 1972, as amended. WITNESS my signature this the _____ day of _______________ , 20 ______ . BY: ____________________________________ _____ ___________________________________ Type or Print Name _____ ___________________________________ Title _____ ___________________________________ Corporation Attest: Secretary STATE OF MISSISSIPPI COUNTY OF ________________ SWORN TO AND SUBSCRIBED before me on this _____ day of ______________ , 20 ______ . __________________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES: _______________ Lien Notice – Corporation Page 2 of 3 EXHIBIT A       Lien Notice – Corporation Page 3 of 3