Claim of Lien Form

After Recording Return to:    










——–Above This Line Reserved For Official Use Only—————-


STATE OF ______________

COUNTY OF _______________.

BEFORE ME, the undersigned notary public, personally appeared ________________________, who was duly sworn and says that he is _________________________ (lienor or agent of lienor) 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, _______________: (legal description) owned by ____________________ of a total value of $ ________________, of which there remains unpaid principal of $ _____________, plus finance charges through ___________, 20 ____, in the amount of $__________ , and additional finance charges that accrue to the date of payment; and furnished the first of the items on ______________, 20____ , and the last of the items on ____________, 20____ ; and (if the lien is claimed by one not in privity with the owner) that the lienor served his notice to owner on ____________, 20____ , by _______________________ (method of delivery); and (if required) that the lienor served copies of the notice on the contractor, _______________, on _________________, 20 ____, by _____________________________(method of delivery), and on the subcontractor, _____________________, on ________________, 20_____ .

Signature of Lienor/Agent _________________________

Printed Name of Lienor/Agent ______________________

Address _______________________________________

STATE OF ______________________

COUNTY OF ____________________

Sworn to and subscribed before me by _________________________ who is personally known to me or produced _________________________ as identification, and who did take an oath, this _____ day of _____________, 20 ___.



Print Name of Notary: _____________________

Commission Expires


State Specific Liens-Mechanic Forms

—- For State Specific Liens- Mechanic Forms you can download in Word format, go to

Inside Claim of Lien Form