Fill and Sign the Sample Notary Acknowledgementsnebraska Secretary of Form

Claim of Lien Page 1 of 2 CLAIM OF LIEN- CORPORATION (NRS § 52-147) STATE OF NEBRASKA COUNTY OF ___________________ Before me, the undersigned notary public, personally appeared ________________________________, who was duly sworn and says that she or he is ________________________________ (a representative or agent of the corporate lienor herein), ________________________________ (title) of ________________________________ (the corporate lienor herein), whose address is _____________________________________________________________________________; and that in accordance with a contract with _________________________________, whose address is ___________________________________________________________________, the lienor furnished labor, services, or materials consisting of ____________________________________________________________________________________________________________________________________________________________ on the following described real property in __________________________________ County, Nebraska: ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ (insert legal description) owned by ______________________________ of a total value of $ __________________, of which there remains unpaid $____________, and furnished the first of the items on __________________, 20______, and the last of the items on __________________, 20______; and (if the lien is claimed by one not in privity with the owner) that the lie nor served her or his notice to owner on __________________, 20______, by ________________________ (method of service); and (if required) that the lienor served copies of the notice on the contrac tor on __________________, 20______, by ________________________ (method of service); and on the subcontractor, ________________________, on __________________, 20______, by ________________________ (method of service). ______________________________ Signature of Lienor/Agent Printed Name of Lienor/Agent Claim of Lien Page 2 of 2 ______________________________ Title______________________________ Name of Corporation Address Attest: Secretary STATE OF NEBRASKA COUNTY OF _________________ Sworn to and subscribed before me by ________________________ (name of officer or agent, title of officer or agent) of __________________________________ (name of corporation) a ______________________ (state or place of incorporation) corporation, who is personally known to me or produced ______________________ as identification, and who did ____ take an oath, this ____ day of __________________, 20____. ______________________________ Notary Public Printed Name: __________________ Title or Rank:___________________ Serial Number, if any: ____________ My Commission Expires: _____________________ Prepared by and Return to: (name and address)