Verified Statement of Lien

VERIFIED STATEMENT OF LIEN

By CORPORATION, LLC, ETC.

(Ala. Code § 35-11-213)

Prepared by:

After Recording, Return to:

State of Alabama )

County of ) ss.

a

(Corporation, LLC, Partnership, etc.)

of files this statement in writing, verified by the oath

who has personal knowledge of the facts herein set forth:

1. That said claims a lien upon the

following property, situated in County, Alabama, to wit:

See Legal Description Attached as Exhibit A incorporated by reference as though set forth in full

Legal Description:

This lien is claim, separately and severally, as to both the buildings and improvements thereon, and the said land.

2. That said lien is claim to secure an indebtedness of $ with interest,

from the day of for: (itemize and/or attach invoices)

See Invoices/Statements Attached as Exhibit B incorporated by reference as though set forth in full

Itemize:

The name of the owner or proprietor of the said property is:

Date:

State of Alabama, County

I, a in and

for said county in said state, hereby certify that who

being duly sworn, doth depose and say: That he has personal knowledge of the facts set forth in the foregoing statement of lien, and that the same are true and correct to the best of his knowledge and belief.

(Signature of Affiant)

State of Alabama

County of

I, a

in and for said County in said State, hereby certify that

whose name as of the

a corporation, is signed to the foregoing conveyance, and who is known to me, acknowledged before me on this day that, being informed of the contents of the conveyance, he, as such officer and with full authority, executed the same voluntarily for and as the act of said corporation.

Given under my hand this day of

EXHIBIT A

Street Address of Property:

Legal Description:

EXHIBIT B

Street Address of Property:

Itemized Statement and Attached Invoices: