Fill and Sign the Notice of Assessment Form

Notice of Lien to a Subdivision Lot Owner for Unpaid Assessment Notice is hereby given that the undersigned (e.g., Name of Homeowners Association) ___________________________________________________________ , whose mailing address is ___________________________________________________ _______________________________________________________________________________________________________________________ (Post Office Box Number or Street Address, City, State, Zip Code) hereby claims and intends to hold and claim a lien upon that certain real property owned by ______________________________________ ______________________ (Name of Owner) situated in _________________________ _____________________________________________ (Name of County and State) , being more particularly described as follows: (Insert Legal Description) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The purpose of this lien is to secure payment of assessments in the sum of $_______________ due on _________________________________________ (Date) and owing to the undersigned (e.g., Name of Homeowners Association) ____________ ________________________________________________________ . The total amount due as of ________________________________________ (Date) is $_______________ and there will be additional charges for collection fees. Said indebtedness accrued pursuant to the [e.g., Declaration of the Covenants and Restrictions for (Name of Subdivision)]___________________________________ _________________________________________________________________________________________________________________________________________________________________________________________ and any amendments thereto filed by the (e.g., Name of Homeowners Association)___________________________________ _____________________________________________ in Book ______ at Page ______ of the __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ (County official’s name, office and address where Deeds are recorded), which obligation was assumed by said owner as a condition of ownership in the aforesaid subdivision for which said owner did by acceptance agree to pay the lien of such assessments as they become due in accordance with the aforesaid (e.g., Declaration) _______________________________________ . WITNESS our signature this the _____ day of ___________________________, 20_____. __________________________________________ (Name of Homeowners Association) By_________________________________________________________________________________ (Name and Office in Association) STATE OF ____________________________________________ COUNTY OF ____________________________________ Personally appeared before me, the undersigned authority in and for said County and State, on this __________________________________________ (Date), within my jurisdiction, the within named _______________________________________________ (Name of Officer) , who acknowledged that he is the _____________________________ _______________________ (Name of Office) of _______________________________ ______________________________________ (Name of Homeowners Association), a ________________________________________________ (name of state) corporation, and that he executed the above and foregoing instrument for and on behalf of said corporation, after being duly authorized so to do. ____________________________________ NOTARY PUBLIC My Commission Expires:_______________________ Note: (Form of acknowledgement may vary from state to state)