Fill and Sign the Statement of Lien by Individual Massachusetts Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: ____________________ Address: _____________________ City: ___________________ State: ______ Zip: __________ Phone: ________________ Fax: ___________________ STATEMENT OF LIEN--INDIVIDUAL (Mass. Gen. Law Ann. chi. 254 §8) COMES NOW, ____________________________________ , and hereby states that $ _________________ is due or is to become due, having accounted for all credits which apply. A brief description of the involved property is ______________________________________________________________________________ _________________________________________________________________ . The name(s) of the Owner(s) as set out in the Notice of Contract is ___________________________________________ . (Use this section for a lien for contractor or subcontractor) The name(s) of the Owner(s) of record at the time the work was performed or at the time of the filing of this statement is ________________________________ . (Use this section for a lien for labor) This the _____ day of __________________ , 20 _______ . ________________________ Signature _____ ___________________ Type or Print Name State of Massachusetts County _____________ On this _______ day of _________, 20 ___, before me the undersigned notary public, personally appeared ________________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were _________________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he or she signed it voluntarily for its stated purpose. _____________________ Notary Public Print Name: ___________________ My commission expires: ____________________ MA chi. 254, § 8