Notice of claim of lien

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:

<Property description.>

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

Signed: _____________________________________
<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 _______________.

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