Fill and Sign the Verified Statement of Lien Form

Verified Statement of Lien – Corporation, etc.Page 1 of 3Prepared by: After Recording, Return to: (Full Name of Party) (Company, if applicable) (Street Address) (City, State and Zip Code) VERIFIED STATEMENT OF LIEN By CORPORATION, LLC, ETC. (Ala. Code § 35-11-213) State of Alabama ) ) ss. County of ) , a (Name of Business) (State Where Formed or Organized) files this statement in writing, verified by the oath (Corporation, LLC, Partnership, etc.) of , who has personal knowledge of the facts herein set (Name of Party Executing Claim) forth:1. That said claims a lien upon the (Name of Business) 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. Verified Statement of Lien – Corporation, etc.Page 2 of 32. That said lien is claim to secure an indebtedness of $ , with interest, from the day of , 20 , 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: (Name of Owner or Proprietor) (Street Address) (City, County, State, Zip Code) Date: (Name of Business Entity) (Signature) (Print or Type Name) (Office, Position, Rank) (Street Address) (City, State, Zip Code) State of Alabama, CountyI, , a , in and (Name of Officer, Notary, etc.) (Position, Office or Rank of Officer) for said county in said state, hereby certify that , who (Name of Party Executing Document) 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) Verified Statement of Lien – Corporation, etc.Page 3 of 3 (Type or Print Name) State of Alabama County of I, ___________________, a _____________________________(name and style of officer) 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 , 20 .(Seal) __________________________Notary Public Verified Statement of Lien – Corporation, etc.Exhibit A EXHIBIT A Street Address of Property: Legal Description: Verified Statement of Lien – Corporation, etc.Exhibit B EXHIBIT B Street Address of Property: Itemized Statement and Attached Invoices: