Form 41 - Mechanic'S Lien Statement - Kansas

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The space above is reserved for REGISTER OF DEEDS
FORM 41
MECHANIC’S LIEN STATEMENT
STATE OF KANSAS
)
)
ss:
______________________ COUNTY )
________________________________________________________________ , being first duly sworn, deposes and says: That he
is the __________________________________ of the _________________________________________________ and that on the
(Owner or Manager)
(Name of Shop or Garage)
_____________ day of _________________________________ A.D., 20______ said ______________________________________
did furnish, repair and equip one certain _________________________________________________________________________
(Automobile or Truck)
belonging to _____________________________________________ , _________________________________________ with labor,
repair and repair parts, said automobile or truck being described as follows, to-wit:
Name of car ________________________________________________ Type _____________________ Year _________________
Motor No. ___________________________________ Serial ___________________________ License _______________________
said equipment being furnished at the instance and request of _____________________________________________________
an itemized statement of which is hereto attached, marked Exhibit “A” and made a part hereof, and that the reasonable
value of said labor and equipment is worth the sum of $ ___________________________________ and that said equipment
was furnished while said vehicle was in the possession of the ______________________________________________________
(Name of Shop or Garage)
that said equipment was furnished and placed on said automobile in the County of __________________________________
State of Kansas, and that this said lien statement is made pursuant to Section 58-201 of Article, Chapter 58, of the
Statutes of Kansas for 1923.
____________________________________________________
Subscribed and sworn before me this ________________ day of ________________________________________ A.D., 20______
____________________________________________________
Notary Public
My Commission Expires ________________________________________________________
MECHANIC’S LIEN RECEIPT
Date _____________________________________________________ File No. ___________________________________________
Mortgagor ________________________________________________ Mortgagee _________________________________________
(Name of Shop or Garage)
Amount $ _______________________________ Description __________________________________________________________
Motor No. ________________________________________________ Date of Filing ______________________________________
_____________________________________________ Register of Deeds, ________________________________________ County
RELEASE OF MECHANIC’S LIEN
_____________________________ , Kansas, _____________________________ , 20______
To Register of Deeds ____________________________________________ , County _____________________________________
You will please release of record the Mechanic’s Lien described above, the same having settled in full.
Signed _________________________________________________________
PS-1925
The space below is reserved for REGISTER OF DEEDS

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