Fill and Sign the Tn Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: ___________________ Address: ___________________ City: ___________________ State: _____ Zip: __________ Phone: ________________ Fax: ________________ Reference Instrument Number: ________________ Notice of Lien -- Individual (Tenn. Code Ann. § 66-11-112) This instrument was prepared by: Name: ___________________________________ Address: _______________________________________________________________ STATE OF TENNESSEE COUNTY OF ____________________ __________________________________ , being first duly sworn, says that he or she as the lien claimant, furnished certain materials or performed certain work or labor in furtherance of improvements to the real property hereinafter described, in pursuance of a certain contract, with __________________________________ , (the owner, prime contractor, remote contractor, or other person, as the case may be), and would provide notice of the following: 1. The first of the work or labor was performed or the first of the material, services, equipment, or machinery was furnished on the _____ day of _______________ , 20 _______ . The last of the work or labor was performed or the last of the material, services, equipment, or machinery was furnished on the _____ day of _______________ , 20 _______ . 2. There is justly and truly due the lien claimant therefor from __________________________________ , (the owner, prime contractor, remote contractor, or other person, as the case may be) over and above all legal setoffs, the sum of _______________ dollars, for which amount the lien claimant claims a lien under T.C.A. §§ 66-11-101, et seq. on the real property, of which __________________________________ is or was the owner, which is described as follows: ________________________________________________________________________ Notice of Lien Page 1 of 2 ________________________________________________________________________ _______________________________________________________________________ . This the _____ day of _________________ , 20 _______ . _________________________ Signature of Lienor _____ ____________________ Type or Print Name Subscribed and sworn to before me on this the _____ day of _____________ , 20 ________ , by said affiant. ______________________________ Notary Public My Commission Expires: ________________ State of Tennessee County of __________________ Personally appeared before me, the undersigned, a Notary Public within and for said State and County aforesaid, duly commissioned and qualified, ________________________ , the within named bargainers, with whom I am personally acquainted, or proved to me on the basis of satisfactory evidence, and who acknowledged that they executed the foregoing instrument for the purposes therein contained. Witness my hand and seal at office this ______ day of __________________ , 20 ______ . Notary Public My commission expires:       Type or Print Name Notice of Lien Page 2 of 2