CLAIM OF LIEN

STATE OF

COUNTY OF

Before me, the undersigned notary public, personally appeared , who was duly sworn and says that he/she 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, Florida (legal description of property):

owned by , of a total value of $______________, of which there remains unpaid $_______________, and furnished the first of the items on___________________,	, and the last of the items on	,

; and (if the lien is claimed by one not in privity with the owner) that the lienor served his notice to owner on ___________________,	by ; and (if required) that the lienor served copies of the notice on the contractor on ________________,	, by and on the subcontractor on ______________,	by	.

Lienor

By:

Print Name:

Print Title:

Address:

STATE OF

COUNTY OF

SWORN TO and subscribed before me this	day of	,

, by (name), as (title) of (name of corporation), a (State) corporation, on behalf of the corporation. He/She [please check as applicable] /______/ is personally known to me, or has produced /______/ his/her (state) driver's license, or /______/ his/her (type of identification) as identification.

(Signature)

(Printed Name)

NOTARY PUBLIC, STATE OF

(Commission Expiration Date)