(Top 3 inches reserved for recording data) AFFIDAVIT OF SERVICE OF MECHANIC'S LIEN STATEMENT by personal service State of Minnesota, County of: I, on (month/day/year) (insert name of party served) Minnesota Uniform Conveyancing Blanks Form 40.4.1 (2011) being duly sworn on oath say: I served a true and correct copy of the attached Mechanic's Lien Statement personally upon who, according to the best information then had, was (check appropriate boxes) the Owner; the Owner's authorized agent; and/or the person who authorized the Work. . (insert place of service) at (signature) Signed and sworn to before me on (month/day/year) , by (insert name of person making statement) . (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) (v2) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com