This Instrument Prepared By:
Name_______________________________
Address _____________________________
WARNING!
THIS LEGAL DOCUMENT REFLECTS THAT A CONSTRUCTION LIEN HAS BEEN PLACED
ON THE REAL PROPERTY LISTED HEREIN. UNLESS
THE OWNER OF SUCH PROPERTY TAKES ACTION TO SHORTEN THE TIME PERIOD, THIS LIEN
MAY REMAIN VALID FOR ONE YEAR FROM THE DATE OF RECORDING, AND SHALL EXPIRE AND
BECOME NULL AND VOID THEREAFTER UNLESS LEGAL PROCEEDINGS HAVE BEEN COMMENCED TO
FORECLOSE OR TO DISCHARGE THIS LIEN.
CLAIM
OF LIEN
STATE
OF FLORIDA,
COUNTY
OF ______________.
BEFORE ME, the undersigned notary
public, personally appeared ________________________, who was duly sworn and
says that he is (lienor or agent of lienor) 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)
owned
by ________________________________ of a total value of $_________________,
of which there remains unpaid principal of $_________________, plus finance
charges through _________________, _____, in the amount of $__________________,
and additional finance charges that accrue to the date of payment; 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 (method of delivery); and (if required)
that the lienor served copies of the notice on the contractor, ___________________________,
on _________________, _______, by__________________________ (method of
delivery), and on the subcontractor, _____________________________, on
__________________, _______.
Signature
of Lienor/Agent
_________________________________ Printed
Name of Lienor/Agent ______________________________
Address
________________________________________________
_______________________________________________________
SWORN TO AND SUBSCRIBED before me by
_______________________________________ who is personally known to me or produced
__________________________________ as identification, and who did _____ take an
oath, this ________ day of _________________________, ______.
Signature
of Notary______________________________________
Printed
Name of Notary __________________________________
Commission
No/Expiration _______________________________
SEAL: