AFFIDAVIT FOR MECHANIC'S LIEN [R.C.§1311.06] State of Ohio County of Cuyahoga ss: whose address is __________________________________________________________being first duly sworn, says that ____________________________________________________ the lien claimant, furnished certain materials or performed certain labor or work in furtherance of improvements located on or removed to the land hereinafter described, in pursuance of a certain contract, with _____________________________________________________________, the owner, part owner, lessee, original contractor, subcontractor, or other person, as the case may be, whose address is ______________________________________________________. The first of the labor or work was performed or material was furnished on the _____ day of _________________, 20___. The last of the last of the labor or work was performed or material was furnished on the ______ day of _________________, 20____ , and there is justly and truly due ______________________________________________, the lien claimant, therefore from ____________________________________________, the owner, part owner, lessee, original contractor, subcontractor, or other person, as the case may be, over and above all legal setoffs, the sum of ______________________________________________ dollars, for which amount ___________________________________________________, the lien claimant, claims a lien on the land, building, or leasehold, of which _______________________________________is or was the owner, part owner, or lessee, as the case may be, which property is described as follows: Cuyahoga County Recorder’s Office Revised 1/2005 American LegalNet, Inc. www.FormsWorkflow.com _____________________________________ (Claimant) _____________________________________ (Claimant) Sworn to before me and subscribed in my presence this_______ day of___________________ , 20_____ _____________________________________ The claim secured by this Mechanic’s Lien has been paid and the Lien is hereby satisfied and discharged. ______________________________________ This document prepared by: Cuyahoga County Recorder’s Office Revised 1/2005 American LegalNet, Inc. www.FormsWorkflow.com