(Top 3 inches reserved for recording data) AFFIDAVIT OF SERVICE OF MECHANIC'S LIEN STATEMENT by certified mail State of Minnesota, County of: I, on (month/day/year) Minnesota Uniform Conveyancing Blanks Form 40.4.2 (2011) being duly sworn on oath say as follows: I served a true and correct copy of the attached Mechanic's Lien Statement by certified mail , (insert name of person served) upon who, according to the best information then had, was (check appropriate boxes) the Owner; the Owner's authorized agent; and/or the person who authorized the Work. , (insert address to which the Statement was mailed) at which was the last known address of said person. (signature) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 40.4.2 Signed and sworn to before me on (month/day/year) , by (insert name of person making statement) . (Stamp) (signature of notarial officer) Title (and Rank): My commission expires: (month/day/year) THIS INSTRUMENT WAS DRAFTED BY: (insert name and address) American LegalNet, Inc. www.FormsWorkFlow.com