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 State of ____________________ County of __________________ Before me, the undersigned notary public, personally appeared ________________________________, who was duly sworn and says that she or 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, Florida: (Legal description of real property) owned by ________________________________ of a total value of $__________, of which there remains unpaid $__________ and furnished the first of the items on ____________, 20__, and the last of the items on ____________, 20__; and if the lien is claimed by one not in privity with the owner that the lienor served her or his notice to owner 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 __________________________________. _____________________________________________ (Signature) Sworn to (or affirmed) and subscribed before me this _____ day of ____________, 20__ , by ___________________________________, who is Personally Known to me OR Produced Identification: Type of Identification Produced_________________________. _____________________________________________ (Signature) _____________________________________________ (Print, Type, or Stamp Commissioned Name of Notary Public) American LegalNet, Inc. www.FormsWorkflow.com