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 Seminole BEFORE ME, the undersigned notary public, personally appeared the undersigned individual who was duly sworn and says that he is the Lienor herein, (the agent of the Lienor herein ), and whose address is: and that in accordance with a contract with Lienor furnished labor, services, or material consisting of on the following described real property in Seminole County, Florida: Owned by whose address is , of which there remains unpaid $ , and furnished the first of, of a total value of $ the items on (date), and the last of the items on (date); and (if the lien is claimed by one not in privity with the owner) that the Lienor served his or her Notice To Owner on (date), by and if required that the Lienor served copies of the (date), by notice on the contractor on and on the subcontractor on (date), by . Lienor's Signature Printed Lienor's Name STATE OF FLORIDA COUNTY OF SEMINOLE Sworn to and subscribed before me this , by day of , who is personally known to me or who has produced as identification and who did/did not take an oath. Notary Public (Print, type, or stamp commissioned name of Notary Public) This instrument prepared by: American LegalNet, Inc. www.FormsWorkflow.com