STATE OF ___________________

COUNTY ___________________

BEFORE ME, the undersigned Notary Public, personally appeared _______________________________ who duly sworn says that he 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, State of _________________________, described as __________________________________________________ and owned by ___________________________________ of a total value of $_________________________ of which there remains unpaid $_________________________, and furnished the first of the items on _________________________, 20_______, by _________________________ and, (if required) that the lienor served copies of the notice on the contractor on _________________________, 20_______, by_________________________, and on the subcontractor on _________________________, 20_______, by ________________________________.




A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

On __________________ before me, ________________________________ (here insert name and title of the officer), personally appeared ________________________________ ________________________________ ________________________________ ________________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.


________________________________         (Seal)