NOTICE OF CLAIM OF LIEN
The undersigned claimant hereby claims a lien under Section <code section> of the Civil Code of the State of <State> and hereby declares the following:
1. That a description of the property sought to be charged with the lien is:
2. That claimant is owed the sum of <amount> Dollars ($<0.00>).
3. That the name of the <owner(s)>, or reputed <owner(s)> of the property <is/are>:
– <list of owners>
4. That the <name(s)> of the <person(s)> by whom claimant was employed or to whom claimant furnished the materials <is/are>:
– <list of customers>
5. That a general statement of the kind of work done and/or materials furnished by claimant, or both is:
<Work performed and/or materials furnished.>
Dated: 05 April, 2005
<Name of claimant>
STATE OF <State>, COUNTY OF <County>, ss.:
I, __________________________________, do hereby certify that on this
______ day of ________, __________, personally appeared before me
known to be the person(s) who executed the foregoing instrument.
Notary Public in and for the State of _________________.
My commission expires _______________.