(Top 3 inches reserved for recording data) MECHANIC'S LIEN STATEMENT by Individual(s) Minn. Stat. 514.08, subd. 2 State of Minnesota, County of Minnesota Uniform Conveyancing Blanks Form 40.1.1 (2011) DATE: (month/day/year) The undersigned hereby gives notice to the public and states as follows: 1. I am the Claimant person acting at the instance of the Claimant and have knowledge of the facts stated herein. (check appropriate box) 2. The Claimant hereby gives notice of intention to claim and hold a lien upon the real property in County, Minnesota, legally described as follows (the "Property"): Check here if all or part of the described real property is Registered (Torrens) 3. The name and mailing address (and license number, if applicable) of the Claimant are as follows: 4. The amount of the lien claimed is Dollars ($ machinery furnished to the Property (the "Work"). 5. The Claimant performed or furnished the following: ) and is due and owing to the Claimant for labor performed or skill, material, or (insert description of Work) 6. The Work was performed or furnished from for or to the following person(s): (insert name of person authorizing Work) (insert first date of Work) to (insert last date of Work) , Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 40.1.1 7. The name of the present owner of the Property (the "Owner"), according to the best information Claimant now has, is: 8. The Claimant acknowledges that a copy of this statement must be served personally or by certified mail on the Owner, the authorized agent of the Owner, or the person who authorized the Work within one hundred twenty (120) days of doing the last Work. 9. Notice as required by Minn. Stat. 514.011, subd. 2, if any, was given. (signature) 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