Mechanic'S Lien - Residential Real Property Form - St.louis County, Missouri Page 2
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1
2Statement of Account
Description of the work performed under the contract:
A copy of any contract, purchase
(Attach additional pages, if necessary.)
order, or proposal and any change order or modification to the agreement under which claimant performed its work on
the property is attached. If there is not a written agreement, provide a general description of the scope of work agreed to
be performed by claimant on the property and the basis for payment for such work as agreed to by claimant and the
contracting party.
________________________________________________________________________________________________
________________________________________________________________________________________________
Total amount claimed for work performed: $ ____________ .
Itemized listing of materials furnished under the contract and the value of each item:
(Attach additional pages, if necessary.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Total amount claimed for materials: $ ____________ .
Total amount of all claims: $ ____________
Total amount of payments/credits:$ ____________
for Total amount due: $ ____________
All invoices for work on the property under this claim are attached.
I have attached a photocopy of the notice of rights and any renewals of notice of rights recorded by or identifying the
claimant. The attached copy(ies) has/have been file stamped by the circuit clerk.
I, ____________________________________________, being of lawful age, being duly sworn on my oath, state
that I prepared this document and that the facts stated above are true and correct according to my best knowledge and
belief.
____________________________________________
____________________________________________
Lien Claimant
By Attorney or Agent for Lien Claimant
Subscribed and sworn to before me on ______________________________________ (date).
_________________________________________________
Notary Public
My commission expires:_____________________________
Certificate of Filing
I, __________________________________________, Clerk of the ___________________________ Court, Division
__________ of ___________________________________ (County/City of St. Louis), hereby certify the attached lien was filed in
my office on ____________________________ (date).
______________________________________ (date)
W
my hand and the seal of the court affixed hereto on
.
ITNESS
____________________________________
(Seal of the Court)
Clerk
OSCA (7-10) GN160
2 of 2
429.005 - 429.360 RSMo
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