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Mechanics Lien Form - Blank

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Recording Requested By and When Recorded Mail To:

Space above this line for recorder’s use only

(To be recorded in the county recorder’s office

in the county in which the property is located.)

MECHANICS LIEN

NOTICE IS HEREBY GIVEN that Claimant

(legal name and address), claims a lien for labor,

service, equipment, or material under the laws of the State of ___________________, upon the premises hereinafter

described, and upon every estate or interest in such structures, improvements and premises held by any party holding any

estate therein. The work was furnished for the construction of those certain buildings, improvements, or structures, now

upon that certain parcel of land situated in the County of ____________________, State of ___________________, said

land described as follows:

STREET ADDRESS: ____________________________________________________________

and/or

LEGAL DESCRIPTION: ____________________________________________________________

The lien is claimed for the following labor, service, equipment or material furnished by the Claimant:

(describe generally). Claimant is owed $

for work furnished to the work of improvement, after deducting

all just credits and offsets, plus interest at the legal rate from the date of this lien. The name of the person or company by

whom Claimant was employed, or to whom Claimant furnished the work is:

The name(s) and address(es) of the owner(s) or reputed owner(s) of the real property is/are:

Name of Claimant:

By:

Date:

__________________________________________________

Signature

Print Name & Authorized Capacity

Verification

I, the undersigned, declare: I am the

(authorized capacity/title), for the Claimant named in the foregoing claim of mechanics lien:

I am authorized to make this verification for the Claimant: I have read the foregoing claim of mechanics lien and know the contents thereof, and the

same is true of my knowledge. I certify (or declare) under penalty of perjury under the laws of the State of ____________ that the foregoing is true

and correct.

Executed on

, 20 _____ at __________________________________ . _____________________________________________

Signature of Claimant or Authorized Agent

C&B Forms - revised March 2012

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Mechanics Lien Form - Blank

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