Fill and Sign the Texas Original Form

Prepared by, recording requested by and return to:       ----------------------Above this Line for Official Use Only---------------------Name:       Company:       Address:       City:       State:       Zip:       Phone:       Fax:       NOTICE OF CONFIDENTIALITY RIGHTS: IF YOU ARE A NATURAL PERSON, YOU MAY REMOVE OR STRIKE ANY OF THE FOLLOWING INFORMATION FROM THIS INSTRUMENT BEFORE IT IS FILED FOR RECORD IN THE PUBLIC RECORDS: YOUR SOCIAL SECURITY NUMBER OR YOUR DRIVER’S LICENSE NUMBER. AFFIDAVIT OF LIEN—CORPORATION—PERSON OTHER THAN ORIGINAL CONTRACTOR- CORPORATION NOTICE: THIS IS NOT A LIEN. THIS IS ONLY AN AFFIDAVIT CLAIMING A LIEN. County of _______________ ) ) State of Texas ) A. Claimant:       Mailing Address:       (street, city, state, and zip code) Physical Address:       (street, city, state, and zip code) claims a mechanics' or materialman’s lien on the real property and improvement in the City of _____________ , County of _______________ , Texas , located at ____________ , _________________ . Affidavit of Lien Page 1 of 4 B. The legal description of the property is: [Insert legal description or attach as Exhibit A]                         C. The following person(s) has an ownership interest in the property or are reputed to have a property interest in said Property:             (Name) (Last Known Address)             (Name) (Last Known Address)             (Name) (Last Known Address) D. Said claim is for the sum of $ _____________ , plus interest at the contract rate or the legal rate, whichever is higher from _____________ , which is due and unpaid to claimant (after deducting any just credits and offsets, if any) for labor, services, equipment and/or materials furnished by claimant and consisting of:                         See attached contracts, invoices or other supporting documents incorporated as: Exhibit Description                                     E. The following is a record of the month in which the work was done and/or materials furnished for which payment is sought: Month/Day/Year Material, labor or services furnished             Affidavit of Lien Page 2 of 4                                                 F. Claimant was employed to furnish the same by ___________________________ , whose address is: _________________________________________________________ furnished the same to _________________________________________ , whose address is: ____________________________________________________________________ . G. The following is a record of the date each notice of the claim was sent to the owner and the method by which the notice was sent: Date Method by which claimant sent notice                                                             H. I f this claim remains unpaid, the owner may be personally liable and the owner's property may be subjected to a lien unless: (1) The owner withholds payments from the contractor for payment of the claim; or (2) The claim is otherwise paid or settled. Dated and sworn to this _____ day of _______________ , 20 ____ at _________________ , ___________ . Signature and Acknowledgment of Corporation By:       Affidavit of Lien Page 3 of 4       Print Name Its:       Attest: Title       Corporate Secretary       Print Name STATE OF TEXAS COUNTY OF ________________ This instrument was acknowledged before me on _____(date)_____ by ________(name of officer)_______ , _________(title of officer)_________ of (name of corporation acknowledging) a (state of incorporation) corporation, on behalf of said corporation. Notary Public       Printed Name 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: Hand Delivery Mailing a true and correct copy of same by Certified or Registered U.S. mail, postage prepaid, to _______________________ , at his usual place of business located at ____________________________________________ . So certified this the _____ day of _______________ , 20 ____ . Signature TX Code § 53.052 Affidavit of Lien Page 4 of 4