IN THE CIRCUIT COURT OF __________________________ COUNTY, 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) Mechanics’/Materialmen’s Lien I, ________________________________________________ (lien claimant) with a view towards availing myself of the benefit of the statutes relating to mechanics’/materialmen’s liens, file the statement of account below. The statement details amounts due for work performed, materials furnished, and/or rental of machinery or equipment under a contract with _____________________________________________ (owner or contractor) for real estate located in _____________________________ County 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.) (Check as applicable.) The last work performed and/or materials 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. With respect to rental machinery or equipment, the last piece of machinery or equipment was removed from the property described above on _________________ (date). NOTE: Liens based on the rental of machinery or equipment must meet the requirements of Section 429.010 (1), (2), and (3), RSMo. The statement of account is filed in order that it may constitute a lien on the property described above. The statement is a true and accurate account of demands due claimant after all appropriate credits have been given. OSCA (10-05) GN 130 1 of 2 429.005 - 429.360 RSMo American LegalNet, Inc. www.FormsWorkflow.com Statement of Account Description of the work performed under the contract: (Attach additional pages, if necessary.) 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: $ ____________ . Itemized listing of any rental machinery or equipment utilized in the performance of the contract with the owner or contractor. Include the reasonable rental value of the machinery or equipment during the period of actual use and any periods of nonuse covered by the terms of the rental contract while the machinery or equipment was on the property: (Attach additional pages, if necessary.) Total amount claimed for the rental of machinery or equipment: $ ____________ . Total amount of all claims: $ ____________ . 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, hereby certify the attached lien was filed in my office on ____________________________ (date). WITNESS my hand and the seal of the court affixed hereto on ______________________________________. Clerk ____________________________________ By: ______________________________________ (Seal of the Court) OSCA (10-05) GN 130 Deputy Clerk 2 of 2 429.005 - 429.360 RSMo American LegalNet, Inc. www.FormsWorkflow.com