Mechanics Lien Form
Instrument Prepared By
And Recording Requested By:
Space Above For Recorder’s Use
Claimant: (Name and Address)
Property Owner: (Name and Address)
Property to be Liened (the “Property”):
The party who hired the Claimant to perform the Services at the Property is (the “Hiring Party”): Name and Address)
Services, labor, materials, equipment, and/or work provided by the Claimant (“Services”):
The CLAIMANT files this Statement in writing, verified by the oath of its disclosed agent, Express Lien, Inc., who has been informed of the facts herein stated, and who believes, upon such information, that the facts set forth in this statement are true in correct; specifically that:
The CLAIMANT furnished the labor and/or materials above-described and identified as the SERVICES to the above-identified PROPERTY, where they were used in the construction of an improvement and/or structure thereupon, and claims a lien upon the above-identified PROPERTY. This lien is claimed, separately and severally, as to both the buildings and improvements thereon, and the said land;
The said lien is claimed to secure an indebtedness of $_________________. This AMOUNT OF CLAIM is true and correct, and is now due and owing to the CLAIMANT after allowing all credits, payments and offsets. The name of the owner or proprietor of the said property is above-identified as the PROPERTY OWNER.
Signature of Claimant, and Verification
Before me, the undersigned Notary Public, in and for the County and State aboveinscribed, personally came and appeared __________________________________, who being duly sworn, doth depose and say: That s/he has been informed of the facts stated in the foregoing statement of lien, and that s/he believes them to be true and correct to the best of his/her information, knowledge and belief. Sworn to, subscribed and signed before me on the above-indicated date, by said affiant.