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[ Claim of Lien Form ]

BEFORE ME, the undersigned Notary Public, personally appeared who duly sworn says that he is (the lienor herein) (the agent of the lienor herein) whose address is and that in accordance with a contract with lienor furnished labor, services or materials consisting of:

on the following described real property in County, State of ,described as and owned by of a total value of dollars ($ ) of which there remains unpaid $ , and furnished the first of the items on, 19 , by and, (if required) that the lienor served copies of the notice on the contractor on, 19 , by ,and on the subcontractor on, 19 , by .



On before me, ,
personally appeared ,
personally known to me (or subscribed to the within instrument and acknowledged to me the person(s) whose name(s) is/are in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.WITNESS my hand and official seal.

Signed Affiant Known Unknown

ID Produced


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