Fill and Sign the Statement Privilege Form

STATEMENT OF CLAIM AND PRIVILEGE- INDIVIDUAL (La.Rev.Stats § 9:4822-G) BE IT KNOWN, that on _____________________, before me, a Notary Public for ________________ Parish, Louisiana, and in the presence of the undersigned competent witnesses, PERSONALLY CAME AND APPEARED: _________________________________, a person of the full age of majority whose municipal address is ___________________________________________________________________________. Hereinafter called APPEARER, who declared that: 1. __________________________________ (hereinafter referred to as OWNER), a person of the full age of majority and owner of the property in controversy, and ___________________________________, a Louisiana company doing business (hereinafter referred to as CONTRACTOR), collectively the parties referred to as DEBTOR, is justly, truly and legally indebted unto APPEARER in the full sum of _____________________ (_____________) DOLLARS, as will appear from invoices attached hereto and marked as Exhibit 1; 2. The account represents work, labor, services and material performed by APPEARER in the construction of improvements upon the property owned by DEBTOR, described as follows: These certain pieces of ground, together with all buildings, component parts, and improvements thereon, and all the rights, ways, privileges, servitudes, appurtenances and advantages thereunto belonging or in anywise appertaining, located in the Parish of _________________, State of Louisiana, described as Square ________, Lot ______, with the municipal address: __________________________________________________________________ __, Accessor’s Parcel Number _____________________. 3. This affidavit is made for the purpose of preserving the lien and privilege granted by law to the APPEARER on the improvements and property above described; 4. The debt, plus costs of filing this affidavit, is past due, owing and unpaid, and all just credits have been allowed; Statement of Claim and Privilege Page 1 of 2 5. APPEARER hereby delivers to the Clerk of Court/Recorder of Mortgages in and for the Parish of __________________ Louisiana, this claim for a lien and privilege and requests that the same be recorded in accordance with the provisions of Louisiana Revised Statutes 9:4801, et seq. THUS DONE AND PASSED in my office in _______________________________, Louisiana, on the day, month and year first above written, in the presence of the undersigned competent witnesses, who have hereunto signed their names with the said appearers and me, Notary, after reading of the whole. Dated: __________________ ________________________________ Signature of Owner ________________________________ Type or Print Name ________________________________ Signature of Contractor ________________________________ Type or Print Name STATE OF LOUISIANA COUNTY OF ___________________ On this _______ day of ________, 20__, __________ before me personally appeared _______________________________, to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that he or she (or they) executed it as his or her (or their) free act and deed. ______________________________ Notary Public ______________________________ Type or Print Name ______________________________ Title (and Rank) (Seal, if any) My appointment expires: ___________________ Statement of Claim and Privilege Page 2 of 2