CLAIM OF LIEN FORM TEMPLATE

This Claim of Lien (“Claim”) is filed on [Date], by:

Claimant: [Full Legal Name / Business Name]
Address: [Claimant’s Address]
Phone: [Phone Number]
Email: [Email Address]

Against Property Owned by: [Owner’s Full Legal Name]
Address: [Owner’s Address]

Property Description: [Full Legal Description of Property, including address, lot, block, subdivision, county, and state]

1. Statement of Claim

The Claimant performed labor, furnished materials, or provided services for the improvement of the property described above under contract with [Name of Contractor/Subcontractor/Owner].

2. Amount Owed

The total amount due and unpaid for such labor, materials, or services is $[Amount]. This amount became due on [Date].

3. Nature of Work

The work performed or materials furnished included:
[Brief description of work or materials provided, e.g., roofing, plumbing, electrical supplies, construction materials].

4. Dates of Work

The work and/or furnishing of materials commenced on [Start Date] and was completed or last provided on [End Date].

5. Legal Right to Lien

The Claimant asserts a lien against the property pursuant to [cite relevant state statute or lien law], securing payment of the unpaid balance for the improvements described herein.

6. Verification

I hereby verify under oath that the foregoing statement is true and correct to the best of my knowledge and belief.

Claimant Signature: ___________________________ Date: ___________
Printed Name: ________________________________

Notary Acknowledgment:
State of [State]
County of [County]

On this ____ day of ________, 20, before me, the undersigned Notary Public, personally appeared [Claimant’s Name], personally known to me or proved by satisfactory evidence to be the individual who executed this instrument, and acknowledged that they executed it for the purposes stated herein.

Notary Public Signature: _______________________
My Commission Expires: ___________