Fill and Sign the Notice Statutory Form

Notice of Statutory Breeder's Lien Please take notice that the undersigned, _________________ (name of owner) , of ____________________________________________________________________ (address of owner) , claims a lien for breeding services, in accordance with the provisions of (cite state statute) ______________________________, as follows: 1. The lien is claimed for services performed on a (description of animal) ______________________________________________________, known as "________________________________ (name of animal) ," Registration No. _______________ (number) ; 2. The (specify animal) __________________________ was serviced on ___________________ (date) , at _____________________________________ ________________________________ (address where services performed) ; 3. The name of the owner of the (specify animal) _____________________ serviced is _______________________ (name) ; 4. The (specify animal) ____________________________ that performed the service is a (describe animal) ____________________________________, known as "___________________________ (name of animal) ," Registration No. ________________ (number) ; 5. The undersigned, ____________________ (name of owner) , is the owner of the (specify animal) _______________________________ performing the service; and 6. This lien is claimed for ________________ (dollar amount) , which is the agreed price of the service. Witness my signature this the ______ day of _______________ 20____. _________________________ (Printed Name of Lienholder) _________________________ (Signature of Lienholder)