STATE OF GEORGIA 

COUNTY OF ______________

CLAIM OF LIEN

1. The name and address of the person claiming the lien is:

2. The Name and Address of the Record Owner of the Real Property claimed to be subject to the lien at the time of the Claim of Lien is filed is:

3. A description of the real property upon which the Lien is claimed: [add legal description here]

[If Claimant has information, then list: Land Lot Number, District Number, Section Number, Block and Phase Unit, if applicable. Also list the street number, if developed property. List the Deed Book and Page of the Deed into Owner if Claimant has it.]

4. The name and address of the person with whom the Lien-Claimant contracted for the furnishing of labor or material is:

5. The date upon which labor or materials were first furnished upon said property by the Lien-Claimant:

6. The date upon which labor or materials were last furnished upon said property by the Lien-Claimant:

7. A general description of the labor performed or material furnished and the amount claimed therefore is:

This the _____ day of ___________, 199__.

_x_______________________

[Name of Individual Claimant or Corporation]

By:______________________

[If a Corp., then, by its:]

Address of Ind. or Corp. claiming lien:

______________________________

______________________________

______________________________

Sworn to and subscribed

before me, this _______

day of ______________, 19___.

______________________________

Notary Public

My Commission expires:

______________________________

[NOTARY SEAL]

Filed this _____ day of ____________, 199___.

By: ________________________________

Clerk, Superior Court

____________ County