IN THE ________ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI Division: Case Number: Lien Claimant: Claimant’s Address: City, State, Zip: Telephone Number: vs. Owner/Lessee/Licensee: Owner/Lessee/Licensee’s Address: City, State, Zip: Telephone Number: (Date File Stamp) Mechanic’s Lien – Residential Real Property As a lien claimant and in accordance with Chapter 429 RSMo, I file the statement of account below. The statement details amounts due for work performed and/or materials furnished under a contract with _______________________________________________________________________________ (name and address of owner or contractor) for real estate located in ___________________________________ (County/City of St. Louis), Missouri and described as follows: (Provide legal description of real estate. Attach additional pages, if necessary.) The property described is subject to the following encumbrance(s) that is/are recorded as follows: (List the type of encumbrance and where it is recorded. Attach additional pages, if necessary.) The last work performed and/or materials or services furnished for the property described above was on ________________________ (date). A demand for the amount due the lien claimant was made within six (6) months prior to filing this lien. The statement of account is filed in order that it may constitute a lien on the property described above. The statement is a just and true account of the demands due claimant after all appropriate credits have been given. OSCA (7-10) GN160 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 429.005 - 429.360 RSMo Statement of Account Description of the work performed under the contract: (Attach additional pages, if necessary.) A copy of any contract, purchase order, or proposal and any change order or modification to the agreement under which claimant performed its work on the property is attached. If there is not a written agreement, provide a general description of the scope of work agreed to be performed by claimant on the property and the basis for payment for such work as agreed to by claimant and the contracting party. Total amount claimed for work performed: $ ____________ . Itemized listing of materials furnished under the contract and the value of each item: (Attach additional pages, if necessary.) Total amount claimed for materials: $ ____________ . Total amount of all claims: $ ____________ Total amount of payments/credits:$ ____________ for Total amount due: $ ____________ All invoices for work on the property under this claim are attached. I have attached a photocopy of the notice of rights and any renewals of notice of rights recorded by or identifying the claimant. The attached copy(ies) has/have been file stamped by the circuit clerk. I, ____________________________________________, being of lawful age, being duly sworn on my oath, state that I prepared this document and that the facts stated above are true and correct according to my best knowledge and belief. ____________________________________________ ____________________________________________ Lien Claimant By Attorney or Agent for Lien Claimant Subscribed and sworn to before me on ______________________________________ (date). ________________________________________________ Notary Public My commission expires:____________________________ Certificate of Filing I, __________________________________________, Clerk of the ___________________________ Court, Division __________ of ___________________________________ (County/City of St. Louis), hereby certify the attached lien was filed in my office on ____________________________ (date). WITNESS my hand and the seal of the court affixed hereto on ______________________________________ (date). (Seal of the Court) ________________________________________________ Clerk OSCA (7-10) GN160 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 429.005 - 429.360 RSMo