Prepared by, and after recording, return to: Name: Address: WARNING TO OWNER: This lien notice creates a lien against the commercial real estate interest of the landlord or tenant from whom the leasing commission is claimed below, and the lien may be foreclosed in the same manner as a mortgage. This lien notice does not create any lien against the interest of the other party to the lease. This lien notice includes information about the lease only for the purpose of defining the scope of the lien claimed below, and pursuant to F.S. 475.807(9) the recording of this lien notice does not constitute notice to any creditor or subsequent purchaser of the existence of any lease described in this lien notice. (Space reserved for Clerk of Court) BROKER'S COMMISSION LIEN NOTICE UNDER FLORIDA COMMERCIAL REAL ESTATE LEASING COMMISSION LIEN ACT Notice is hereby given pursuant to the Florida Commercial Real Estate Leasing Commission Lien Act, Part IV of Chapter 475, Florida Statutes (the "Act"), that the undersigned real estate broker is entitled to receive a leasing commission from the owner named below pursuant to the terms of a written brokerage commission agreement regarding a lease of the commercial real estate described below, and the undersigned broker claims a lien under the Act against the owner's interest in the commercial real estate in the amount set forth below. 1. 2. 3. 4. Name of the owner who is obligated to pay the commission: The owner obligated to pay the commission is [check one]: [ ] the landlord under the lease. [ ] the tenant under the lease. Name of the person owning the fee simple interest in the commercial real estate, if other than the owner who is obligated to pay the commission: Legal description of the commercial real estate: . 5. Name, mailing address, telephone number, and Florida broker license number of the undersigned broker: Name: ___________________________________ Telephone number: ________________ License number: Mailing address: Effective date of the written brokerage commission agreement between the owner and the broker under which the commission is or will be payable: _______________, 20__. Amount of commission claimed by the undersigned broker: $______________, or ____________ percent of rents payable under the lease, or [specify other formula for determination of commission amount]: The lease for which the commission is claimed is described as follows [provide all information known to the broker]: Name of landlord: Name of tenant: Date of lease: Leased premises: Is the undersigned broker claiming an "automatic renewal commission" as defined in the Act? (i.e., is the undersigned broker claiming a commission that may become payable if the lease is later renewed or modified to expand the leased premises or to extend the lease term, but the written brokerage commission agreement does not expressly require the broker to perform any additional services in order to receive this later commission?) [check Yes or No]: [ ] YES [ ] NO If the answer to item 9 is "YES," specify the amount of the automatic renewal commission or the formula for computing the automatic renewal commission: 6. 7. . 8. 9. 10. The expiration date of this lien notice is two (2) years after the date of recording, unless the answer to item 9 is YES, in which case the expiration date of this lien notice for the automatic renewal commission described in item 9 is ten (10) years after the date of recording. 11. The undersigned broker, under penalty of perjury, hereby swears or affirms that the undersigned broker has read this lien notice, knows its contents and believes the same to be true and correct, and that the undersigned broker is making this commission claim pursuant to the written brokerage commission agreement described in this lien notice. State of _____________________ ) County of ___________________ ) Signed: Print Broker's name: (Broker) Signed and sworn to or affirmed under penalty of perjury before me, a notary public, this _____ day of ____________, 20__, by ______________________________, who is personally known to me or produced ____________________ as identification. My commission expires: ____________________ [NOTARY SEAL] Form 475.805rv1 - Leasing Lien Notice.doc Signed: Notary Public, State of Print Notary's name: