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 (Section 713.08, Florida Statutes) STATE OF FLORIDA COUNTY OF LEON BEFORE ME, personally appeared ________________________________________________, who was duly sworn and says that she/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 located in Leon County, Florida: owned by ______________________________________________________________, of a total value of $______________________, of which there remains unpaid $______________________, and furnished the first of the items on _______________________, _______; and the last of the items on __________________________, _______; and that lienor served his Notice to Owner on __________________________, _______, by ____________________________________________, and (if the lien is claimed by one not in privity with the owner) that the lienor served copies of the Notice on the contractor on __________________________, _______, by ________________________, and on the subcontractor on __________________________, _______, by_________________________. _________________________________________ ____________________________________ print or type name State of Florida County of Leon The foregoing instrument was acknowledged before me this ___ day of __________, 20 ___, A. D., _____________________________________________________ who is personally known to me or who has produced __________________________ as identification, and who did/did not take an oath. Gwen Marshall, Leon Co. Clerk of the Circuit Court & Comptroller Prepared By: _______________________________ _________________________________________________ _________________________________________________ _____________________________________________ Notary Public / Deputy Clerk ____________________________________________________ Print or type name American LegalNet, Inc. My Commission Expires: www.FormsWorkFlow.com