Fill and Sign the Statement of Lien Individual Minnesota 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 (M.S.A. § 514.08) COMES NOW, _______________________________ , as a party which has supplied labor, skill or material for the improvement of property and would state as follows: 1. The undersigned corporate lien claimant hereby provides notice of the intention to claim and hold a lien in the amount of $ _________________ . 2. Said amount is due and owing to the undersigned for labor performed, or for skill, material, or machinery furnished, specifically: __________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________ . 3. The name of the claimant is ________________________________ . 4. Labor, skill, or materials were provided to ________________________________________ . 5. Labor, skill, or material was first provided on the _____ day of _______________ , 20 ______ . 6. Labor, skill, or material was last provided on the _____ , _________________ , 20 ________ . 7. The property to which the above was provided is described as _________________________________________________________________ . 8. On information and belief, the above-described property is owned by _________________________________________________________________ . 9. The undersigned lien claimant’s post office address, if any, is _________________________________________________________________ . 10. The lien claimant hereby acknowledges that a copy of this statement must be served personally or by certified mail within the 120-day period provided by the Minnesota Code on the owner, the owner's authorized agent or the person who entered into the contract with the contractor as provided herein. 11. The notice as required by section 514.011, subdivision 2, of the Minnesota Statutes Annotated, if any, was given. This the _____ day of ______________ , 20 ______ . __________________________ Signature _____ _____________________ Type or Print Name This instrument was drafted by ________________ (name) of _____________________________________________________________________ (address). STATE OF MINNESOTA COUNTY OF ________________ This instrument was acknowledged before me on _____ day of _______________ , ___________ , by ________________________________ , (name(s) of person(s)). ___________________________ Notary Public (Seal, if any) Print Name: _________________ Title (and Rank):________________ My commission expires: _______________ Certificate of Delivery I, ___________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to _________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to _________________________________________ , within 120 days as provided by Minn. Stat. § 514.08. So certified this the _____ day of ______________ , 20 ______ . ________________________ Signature