Mechanics Lien Form

Instrument Prepared By
And Recording Requested By:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Space Above For Recorder’s Use

Statement of Mechanics Lien

Lienor: &(Name and Address)

 

 

 

 

Property Owner:

 

 

 

 

The party who hired the Claimant to perform the Services at the Property is ("Hiring Party"):

 

 

 

 

 

 

 

 

Services, labor, materials, equipment and/or work provided by the Lienor ("Services"):

 

 

Services were supplied in the improvement and/or construction of real property described as follows (the "Property"):

 

 

 

 

Amount of Claim: $___________________________

© 2012 Express Lien, Inc. dba Zlien

HEREIN APPEARS, the LIENOR, who is represented by its disclosed and limited agent, Express Lien, Inc., d/b/a Zlien appointed for the purposes of filing and signing this Statement of Account and Claim of Lien. The LIENOR states under oath:

That the LIENOR 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. The SERVICES were provided pursuant to a contract made between the LIENOR and the aboveidentified HIRING PARTY.

The above-identified AMOUNT OF CLAIM is true and correct, and that this amount is now due and owing to the LIENOR after allowing all credits, payments and offsets.

The LIENOR hereby claims a lien on or in the PROPERTY, owned by the aboveidentified PROPERTY OWNER, to secure payment of the AMOUNT OF CLAIM.

Made Exhibits to this Statement of Account and Claim of Lien, and incorporated herein, are the following:

EXHIBIT 1:

(Statement, Invoice, Contract, or other document showing SERVICES and/or AMOUNT OF CLAIM)

EXHIBIT 2: The Notice of Intent to Lien delivered, and proof of delivery

EXHIBIT 3: The Notice to Owner and Contractor delivered, and Proof of Delivery. (Provide when filing lien against non-residential projects)

EXHIBIT 4: The Pre-Construction Notice to Owner and proof of delivery. (Provide when filing lien against non-residential projects)

The Notices required by Ark. Code Ann. Sec's 18-14-114 - 18-44-116 are attached to this Statement as above-indicated. The dates and affirmation of their delivery are included with the attached Exhibits.

This lien is filed by the LIENOR, and the LIENOR is authorized to release the lien.

[This Space is intentionally left blank. Please see subsequent page.]

© 2012 Express Lien, Inc. dba Zlien

Signature of Claimant, and Verification

State of Arkansas
County of

I, ___________________, the undersigned, being of lawful age and being first duly sworn upon oath, do state that I am the Claimant named herein, or an authorized agent of the Claimant appointed for the purposes of signing and filing this Notice of Claim of Lien, and that I have read the foregoing Notice of Claim of Lien, know the contents thereof, and I have been provided and thereby have knowledge of the facts, and certify that based thereupon, upon my information and belief the foregoing is true and correct, and that I believe them to be true.

Claimant

Signed by Authorized and Disclosed Agent

Print Name:
Dated:

Sworn to and subscribed before me, undersigned Notary Public in and for the above listed State and County/Parish, on this _______________________, by _______________________, who is known to me, or satisfactorily proved to me, to be the person whose name is subscribed to this document, and who acknowledged that he/she executed this document in the capacity indicated for the principal named.

Notary Public
© 2012 Express Lien, Inc. dba Zlien
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