x-none)x-noneCOUNTY OF LA SALLEx-none)x-noneTHE CLAIMANTx-noneofx-noneCounty of x-noneState of x-nonehereby filex-nonea Claim for Lien againstx-noneand Claim for Lien againstx-noneof x-noneCounty, of the State of Illinois, and state x-none;x-noneTHAT on the x-noneday of x-none, said x-nonewas the owner of the following desdcribed land, to wit:x-nonePermanent Index Numberx-noneAddressx-noneThat on the x-noneday ofx-nonethe claimantx-nonemade a contract with said owner x-none(2) to x-nonefor the building (3)x-noneerected on said land for the sum ofx-none$x-noneand on thex-noneday ofx-nonecompleted thereunder (4)x-nonePage 1 of 2 Pages x-noneSTATE OF ILLINOIS COUNTY OF LASALLE x-noneSTATE OF ILLINOIS x-noneSS x-noneORIGINAL CONTRACTOR'S x-noneCLAIM FOR LIEN x-none(over) x-nonevs. x-none20 x-none20 x-none20 x-none(1) x-noneOriginal Contractor's Claim for Lien NO. 200 American LegalNet, Inc. www.FormsWorkFlow.com x-noneSUBCONTRACTOR'S CLAIM FOR LIENx-none(1) If contract made with other than owner, erase "said owner," name such person and add "authorized and permitted by saidx-noneowner to make said contract." x-none(2) State what was done x-none(3) "being," or "to be," as the cause may be.x-none(4) "All required to be done by said contract," or "work to the value of," or delivery of materials to the value ofx-none$ x-none, as set forth in an account thereof herewith filed and made part of, marked Exhibit x-noneas the case may be.x-none*That the Claimantx-nonedid extra and additional work on, and delivered extra and additional material at said premises of thex-nonevalue of $x-noneat the special instance and request of saidx-noneas fully set forth in an account thereof herewith filed and made part hereof, marked Exhibitx-noneand completed same on the x-noneday ofx-none. x-noneThat said owner x-noneentitled to credits on account thereof, as follows, to wit;x-noneleaving due, unpaid and owing to the Claimantx-noneon account thereof, after allowing all credits, the balance ofx-none$x-nonefor which, with interest, the Claimantx-noneclaimx-nonea lien on said land and improvements.x-noneSignaturex-noneSTATE OF ILLINOISx-none)x-noneCOUNTY OF LASALLEx-none)x-noneThe affiantx-nonebeing first duly sworn on oath deposes and says, that he isx-noneof the Claimantx-none: that he has read the foregoing notice and Claim for Lien, knows the contents thereof, and that all thex-nonestatements therein contained are true.x-noneSignaturex-noneSubscribed and sworn before me thisx-noneday ofx-none, A.D. 20x-noneThis instrument prepared by:x-noneNamex-noneAddress x-none20 x-nonePage 2 of 2 Pages x-noneSS x-noneNotary Public American LegalNet, Inc. www.FormsWorkFlow.com