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USER NOTES
California Civil Code §1189 requires that notary acknowledgments must follow the exact language in it. Before 2006, notary acknowledgements only had to be "substantially similar" to Civil Code §1189's language. Starting in 2006, notary acknowledgments must use the section's exact language.
The text of these forms can be copied into documents by clicking and dragging to define the needed text. Then, click on the edit button at the top of the browser screen and click on the copy function. The defined text then can be pasted into a document.
These forms are provided purely as a service to visitors to this Web site. They do not constitute legal advice or representation. If you have any questions about how to complete the forms, which forms to use, when to use them or other questions, consult an attorney. These forms are subject to the Terms and Conditions governing this Web site.
Please note that mechanic's liens, stop notices, and bond claims involve economic rights of yours and other people. If unsure about their appropriate use in a particular circumstance, consult an attorney.
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PRELIMINARY 20-DAY NOTICE (PRIVATE WORK) (California Civil Code §3097)
This is not a lien, only a notice. This notice is not a reflection
on the integrity of any contractor, subcontractor or material
supplier. It simply gives notice of persons providing labor,
services, materials or equipment to the project who are
not under direct contract with the project owner but who
wish to preserve their statutory mechanic's lien, stop notice
and bond rights.
TO:
THE OWNER OR REPUTED OWNER:
___________________________________________
___________________________________________
___________________________________________
(Name/Address)
THE ORIGINAL CONTRACTOR OR REPUTED ORIGINAL CONTRACTOR:
___________________________________________
___________________________________________
___________________________________________
(Name/Address)
THE
CONSTRUCTION LENDER, IF ANY, OR REPUTED CONSTRUCTION LENDER,
IF ANY:
___________________________________________
___________________________________________
___________________________________________
(Name/Address)
1. The name and address of the person/entity furnishing
the labor, services, equipment or materials (use name of
entity holding license):
___________________________________________
___________________________________________
___________________________________________
2. The general description of the labor, services,
equipment or materials furnished or to be furnished by the
undersigned:
___________________________________________
___________________________________________
___________________________________________
3. Date Claimant first provided said labor, services,
equipment or materials:
___________________________________________
___________________________________________
___________________________________________
4. Estimated total price: $ _____________________
5. The name of the person/entity who contracted for
purchase of the labor, services, equipment or materials:
___________________________________________
___________________________________________
___________________________________________
6. Description of the jobsite sufficient for identification:
___________________________________________
___________________________________________
___________________________________________
7. The identity and address of the trust fund(s)
(if required pursuant to a collective bargaining agreement
to pay supplemental fringe benefits into an express trust
fund described in Civil Code §3111):
___________________________________________
___________________________________________
___________________________________________
___________________________________________
NOTICE TO PROPERTY OWNER
If bills are not paid in full for the labor, services, equipment,
or materials furnished or to be furnished, a mechanic's
lien leading to the loss, through court foreclosure proceedings,
of all or part of your property being so improved may be
placed against the property even though you have paid your
contractor in full. You may wish to protect yourself against
this consequence by (1) requiring your contractor to furnish
a signed release by the person or firm giving you this notice
before making payment to your contractor, or (2) any other
method or device that is appropriate under the circumstances.
Other than residential homeowners of dwellings containing fewer than five units, private project owners must notify the
original contractor and any lien claimant who has provided
the owner with a preliminary 20-day lien notice in accordance
with Section 3097 of the Civil Code that a notice of completion
or notice of cessation has been recorded within 10 days
of its recordation. Notice shall be by registered mail,
certified mail, or first-class mail, evidenced by a certificate
of mailing. Failure to notify will extend the deadlines
to record a lien.
Dated: ____________________
________________________________________
(Name of Claimant)
By:_____________________________________
(Signature)
________________________________________
(Print or Type Name and Title)
PROOF OF SERVICE AFFIDAVIT I,__________________________,
declare that I served the above Preliminary Notice by (check
appropriate box below):
[
] Personally delivering a copy to :
__________________________________________
(Name and title or capacity of person served)
at_________________________________________,
__________________________________________
(Address)
on
_________________,__________, at ____ __ m.
(Date) (Year) (Time)
[ ] By First Class Certified or Registered Mail service,
postage prepaid, return receipt requested, addressed to
the party at the address shown below:
___________________________________________
___________________________________________
___________________________________________
(Name/Address)
I declare under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.
Signed
at ___________________________,_______
(Location)
on
_____________________
(Date)
Signature
of person making service:
___________________________________________
[Use the Postal Service's Return Receipt Requested service.
Under Civil Code §3097.1, service by mail is proved
with the signed Proof of Service Affidavit (above) accompanied
by either: 1.) the return receipt for certified or registered
mail delivery; or 2.) by a photocopy of the record of delivery
and receipt maintained by the Postal Service showing the
date of delivery and to whom delivered; or 3.) by the returned
envelope itself in the event of nondelivery.]
[Prepare
one Proof of Service for each person served.]
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PRELIMINARY
20-DAY NOTICE (PUBLIC WORK)
(California Civil Code §3098)
TO:
THE PUBLIC AGENCY:
___________________________________________
___________________________________________
____________________________________________
(Name/Address)
THE ORIGINAL CONTRACTOR OR REPUTED ORIGINAL CONTRACTOR:
___________________________________________
___________________________________________
____________________________________________
(Name/Address)
1. The name and address of the person/entity furnishing
the labor, services, equipment or materials (use name of
entity holding license):
___________________________________________
___________________________________________
___________________________________________
2. The general description of the labor, services,
equipment, or materials furnished or to be furnished by
the undersigned:
___________________________________________
___________________________________________
___________________________________________
3. Date Claimant first provided said labor, services,
equipment or materials:
___________________________________________
___________________________________________
4.
Estimated total price: $_______________________
5. The name of the person/entity who contracted for
purchase of the labor, services, equipment or materials:
___________________________________________
___________________________________________
___________________________________________
6. Description of the jobsite sufficient for identification:
___________________________________________
___________________________________________
___________________________________________
Dated: ____________________
____________________________________________
(Claimant's Name)
By:_________________________________________
(Signature)
____________________________________________
(Print or Type Name/Title)
PROOF OF SERVICE AFFIDAVIT
I,__________________________,
declare that I served the above Preliminary Notice by (check
appropriate box below):
[
] Personally delivering a copy to :
____________________________________________
(Name and title or capacity of person served)
at___________________________________________,
____________________________________________
(Address)
on
_________________,__________, at ___ __ m.
(Date) (Year) (Time)
[ ] By First Class Certified or Registered Mail service,
postage prepaid, return receipt requested, addressed to
the party at the address shown below:
___________________________________________
___________________________________________
___________________________________________
(Name/Address)
I declare under penalty of perjury under the laws of the
state of California that the foregoing is true and correct.
Signed
at ____________________________________
(Location)
on
_____________________
(Date)
Signature
of person making service:
___________________________________________
[Use the Postal Service's Return Receipt Requested service.
Keep the signed Proof of Service Affidavit (above) and the
return receipt for certified or registered mail delivery.
Civil Code §3098 provides that for "any public
works constructed by the Department of Public Works or the
Department of General Services of the state," the 20-day
notice, if served by mail, must be "addressed to the
office of the disbursing officer of the department constructing
the work" or must be personally served upon that officer.]
[Prepare
one Proof of Service for each person served.]
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ATTACHMENT FOR HOME IMPROVEMENT PROJECTS
(16 California Code of Regulations §872)
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Information
about Commercial General Liability Insurance
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Did
your contractor tell you whether he or she carries
Commercial General Liability Insurance?
Home
improvement contractors are required by law to tell
you whether or not they carry Commercial General Liability
Insurance. This written statement must accompany the
bid, if there is one, and the contract.
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What does this insurance cover?
Commercial
General Liability Insurance can protect against third-party
bodily injury and accidental property damage. It is
not intended to cover the work the contractor performs.
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Is this insurance required?
No.
But the Contractors State License Board strongly recommends
that all contractors carry it. The Board cautions
you to evaluate the risk to your family and property
when you hire a contractor who is not insured. Ask
yourself, if something went wrong, would this contractor
be able to cover losses ordinarily covered by insurance?
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How
can you make sure the contractor is insured?
If
he or she is insured, the contractor is required by
law to provide you with the name and telephone number
of the insurance company. Check with the insurance
company to verify that the contractor's insurance
coverage will cover your project.
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What about a contractor who is self-insured?
A
self-insured contractor has made a business decision
to be personally responsible for losses that would
ordinarily be covered by insurance. Before contracting
with a self-insured contractor, ask yourself, if something
went wrong, would this contractor be able to cover
losses that should be covered by insurance?
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For
more information about Commercial General Liability Insurance,
contact the Contractors State License Board at www.cslb.ca.gov
or call 800-321-CSLB (2752).
[Formatting:
The regulation provides: "The heading shall be printed
in at least 14-point type, the questions in at least 12-point
type, and the comments in italics of at least 11-point type.
The text should be bold where indicated."]
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ATTACHMENT FOR CONSTRUCTION OF SINGLE-FAMILY RESIDENCES
(16 California Code of Regulations §872)
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Information
about Commercial General Liability Insurance
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Did
your contractor tell you whether he or she carries
Commercial General Liability Insurance?
Contractors
building single-family residences for owners who intend
to occupy the home for at least a year are required
by law to tell you whether or not they carry Commercial
General Liability Insurance. This written statement
must accompany the contract.
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What
does this insurance cover?
Commercial
General Liability Insurance can protect against third-party
bodily injury and accidental property damage. It is
not intended to cover the work the contractor performs.
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Is
this insurance required?
No.
But the Contractors State License Board strongly recommends
that all contractors carry it. The Board cautions
you to evaluate the risk to your family and property
when you hire a contractor who is not insured. Ask
yourself, if something went wrong, would this contractor
be able to cover losses ordinarily covered by insurance?
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How
can you make sure the contractor is insured?
If
he or she is insured, the contractor is required by
law to provide you with the name and telephone number
of the insurance company. Check with the insurance
company to verify that the contractor's insurance
coverage will cover your project.
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What
about a contractor who is self-insured?
A
self-insured contractor has made a business decision
to be personally responsible for losses that would
ordinarily be covered by insurance. Before contracting
with a self-insured contractor, ask yourself, if something
went wrong, would this contractor be able to cover
losses that should be covered by insurance?
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For
more information about Commercial General Liability Insurance,
contact the Contractors State License Board at www.cslb.ca.gov
or call 800-321-CSLB (2752).
[Formatting:
The regulation provides: "The heading shall be printed
in at least 14-point type, the questions in at least 12-point
type, and the comments in italics of at least 11-point type.
The text should be bold where indicated."]
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CHECKLIST FOR HOME IMPROVEMENT CONTRACTS WITHOUT SWIMMING
POOLS
(16 California Code of Regulations §872.1)
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Check
Out Your Contractor
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Did
you contact the Contractors State License Board (CSLB)
to check the status of the contractor's license?
Contact
the CSLB at 1-800-321-CSLB (2752)
or visit our web site: www.cslb.ca.gov.
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Did
you get at least 3 local references from the contractors
you are considering?
Did
you call them?
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Building
Permits - will the contractor get a permit before
the work starts?
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Check
Out the Contract
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Did
you read and do you understand your contract?
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Does the 3-day right to cancel a contract apply to
you?
Contact
the CSLB if you don't know.
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Does
the contract tell you when work will start and end?
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Does
the contract include a detailed description of the
work to be done, the material to be used, and equipment
to be installed?
This
description should include brand names, model numbers,
quantities and colors. Specific descriptions now will
prevent disputes later.
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Are
you required to pay a down payment?
If
you are, the down payment should never be more than
10% of the contract price or $1,000, whichever is
less.
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Is
there a schedule of payments?
If
there is a schedule of payments, you should pay only
as work is completed and not before. There are some
exceptions - contact the CSLB to find out what they
are.
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Did your contractor give you a "Notice to Owner,"
a warning notice describing liens and ways to prevent
them?
Even
if you pay your contractor, a lien can be placed on
your home by unpaid laborers, subcontractors or material
suppliers. A lien can result in you paying twice or,
in some cases, losing your home in a foreclosure.
Check the "Notice to Owner" for ways to
protect yourself.
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Did
you know changes or additions to your contract must
be in writing?
Putting
changes in writing reduces the possibility of a later
dispute.
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[Formatting:
The regulation provides: "The heading shall be printed
in at least 14-point type, the questions in at least 12-point
type, and the comments in italics of at least 11-point type.
The text should be bold where indicated."] |
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CHECKLIST FOR HOME IMPROVEMENT CONTRACTS
WITH SWIMMING POOLS
(18 California Code of Regulations §872.1)
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Check
Out Your Contractor
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Did
you contact the Contractors State License Board (CSLB)
to check the status of the contractor's license?
Contact
the CSLB at 1-800-321-CSLB (2752) or visit
our web site: www.cslb.ca.gov.
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Did
you get at least 3 local references from the contractors
you are considering?
Did
you call them?
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Building
permits - will the contractor get a permit before
the work starts?
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Check
Out the Contract
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Did
you read and do you understand your contract?
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Does
the 3-day right to cancel a contract apply to you?
Contact
the CSLB if you don't know.
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Does
the contract tell you when work will start and end?
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Does the contract include a complete description of
the work to be done, the material that will be used
and equipment to be installed?
This
description should include a plan and scale drawing
showing the shape, size, dimensions and specifications.
It should include brand names, model numbers, quantities
and colors. Specific descriptions now will prevent
disputes later.
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Are
you required to pay a down payment?
The
down payment for swimming pools should never be more
than 2% of the contract price or $200, whichever is
less.
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Is
there a schedule of payments?
If
there is a schedule of payments, you should pay only
as work is completed and not before. There are some
exceptions - contact the CSLB to find out what they
are.
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Did
your contractor give you a "Notice to Owner,"
a warning notice describing liens and ways to prevent
them?
Even
if you pay your contractor, a lien can be placed on
your home by unpaid laborers, subcontractors, or material
suppliers. A lien can result in you paying twice or,
in some cases, losing your home in a foreclosure.
Check the "Notice to Owner" for ways to
protect yourself.
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Did you know changes or additions to your contract
must all be in writing?
Putting
changes in writing reduces the possibility of a later
dispute.
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[Formatting: The regulation provides: "The heading
shall be printed in at least 14-point type, the questions
in at least 12-point type, and the comments in italics of
at least 11-point type. The text should be bold where
indicated."] |
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Recorded at the request of
and to be returned to:
(Notice giver's name, address, city, state, ZIP code)
NOTICE
OF NON-RESPONSIBILITY
(California Civil Code §3094)
NOTICE
IS HEREBY GIVEN THAT:
1.
I, the undersigned, am the ___________________ (office/position)
of _______________ (notice giver's name) and have the necessary
authority to verify this document for ____________________
(notice giver's name).
2.
________________________ (notice giver's name) is the _____________
(nature of property interest, such as owner in fee simple)
of that certain property located at: _______________________________
(address, city, state), which is further described as: _______________________________________
(legal description and parcel number) in the property records
of ________ County, California.
3.
The name of the purchaser under contract and/or the lessee
is ______________.
4.
Within the last ten (10) days, _______________________ (notice
giver's name) has obtained knowledge that improvements,
namely ________ (describe the work), are being made on the
property described above.
5.
_____________________ (notice giver's name) has not caused
this work to be performed and will not be responsible for
its performance or for any claims that arise out its performance.
Furthermore, _______________________ (notice giver's name)
will not be responsible for the payment of any labor, services
or materials used or to be used therein or in connection
therewith.
6.
_________________ (notice giver's name) will post this notice
at the property described above and cause this notice to
be recorded within ten (10) days of first obtaining knowledge
of the work described herein.
_____________________________________
(Notice giver's name)
By: _________________________________
(Authorized person signing)
_____________________________________
(Position of person signing)
VERIFICATION
I,
the undersigned, say I am the __________________ (position
of person signing) of _____________________ (notice giver's
name). I have read the above Notice of Non-Responsibility,
know the contents of it and it is true of my own knowledge.
This is a true and correct copy of the Notice of Non-Responsibility
to be posted at the property described above.
I
declare under penalty of perjury that the foregoing is true
and correct.
Executed
on ____________, ____ (date this document was signed) at
_______________________, California (name of city where
signed).
____________________________________________
(Personal signature of person providing the verification)
CERTIFICATE OF ACKNOWLEDGEMENT
| STATE
OF CALIFORNIA |
) |
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ss |
| County
of ____________ |
) |
On __________________ __, 200__ before me, _______________________________________, [name of notary] Notary Public, personally appeared ______________________________________________, [name(s) of signer(s)] who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS
my hand and official seal.
Signature : __________________________ (Seal)
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Recorded at the request of
and to be returned to:
(Notice giver's name, address, city, state, ZIP code)
NOTICE
OF CESSATION
(California Civil Code §3092)
1.
The full name of the owner is:
_______________________________________
2. The address of the owner is:
_______________________________________
_______________________________________
3. The nature of the property interest or estate
of the owner is:
_______________________________________
_______________________________________
4. A description of the site sufficient for identification
is:
_______________________________________
_______________________________________
_______________________________________
(Include the street address if any and city, county and
state)
5. The name of the original contractor is:
_______________________________________
6. The kind of work done or materials furnished pursuant
to the contract is:
_______________________________________
_______________________________________
7. The names and addresses of all persons, if any,
who hold an interest or estate with the owner as joint tenants
or as tenants in common are:
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
8. The full names and full addresses of the predecessors
in interest of the owner if the property was transferred
after the work or improvement referred to in this notice
began:
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
_______________________________________
_______________________________________
_______________________________________
(Name/Address)
9. The work of improvement, described in Paragraph
6, on the property ceased on ______________ (date), and
the cessation has continued to the giving of this notice.
Dated: _______________
_______________________________________
(Owner's Name)
By_____________________________________
(Signature)
VERIFICATION
I,
the undersigned, say:
I
am the ________________________________
(Owner, officer of owning entity, agent of owner, etc.)
of
the interest or estate, described in Paragraph 3, of the
property, described in Paragraph 4;
I
have read the foregoing notice and know and understand the
contents of it, and the facts stated in it are true and
correct.
I
declare under penalty of perjury that the foregoing is true
and correct.
Executed
on _____________________, ______, (date)
at
_____________________________________
(Place where signed)
_______________________________________
(Personal signature)
CERTIFICATE OF ACKNOWLEDGEMENT
| STATE
OF CALIFORNIA |
) |
| |
)
ss |
| County
of ____________ |
) |
On __________________ __, 200__ before me, _______________________________________, [name of notary] Notary Public, personally appeared ______________________________________________, [name(s) of signer(s)] who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature : __________________________ (Seal)
CERTIFICATE OF MAILING
I hereby declare that, pursuant to the requirements of Civil Code §3259.5, I sent notification of recordation of the attached Notice of Cessation to the below-listed person or entity on _________ ___, 200_. Furthermore, I declare that this notice of recordation was sent by [registered mail, certified mail or first class mail]. The notice of recordation was provided within 10 days of recordation of the Notice of Cessation:
_______________________________________
_______________________________________
_______________________________________
(Name/Address from Preliminary 20-Day Notice or from contract with Original Contractor)
I declare under penalty of perjury of the laws of the State of California that the foregoing is true and correct.
Signed at: ______________________________
(Location)
on ____________________________________
(Date)
Signature of person making service
_______________________________________
[It is advisable to use the Postal Service's Return Receipt Requested service. Under Civil Code §3259.5, failure to provide notification of recording of the Notice of Cessation within 10 days extends the time within which a mechanic's lien may be recorded or a stop notice served to 90 days beyond the date the Notice of Cessation was recorded. Notification is evidenced by a certificate of mailing.]
[Prepare one Proof of Service for each person served.]
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Recorded at the request of
and to be returned to:
(Notice giver's name, address, city, state, ZIP code)
NOTICE
OF COMPLETION
(California Civil Code §3093)
1.
The full name of the owner is:
__________________________________________
2. The address of the owner is:
__________________________________________
__________________________________________
3. The nature of the property interest or estate
of the owner is:
__________________________________________
__________________________________________
4. A description of the site sufficient for identification
is:
__________________________________________
__________________________________________
__________________________________________
(Include the street address if any and city, county and
state)
5. The name of the original contractor is:
__________________________________________
6. The kind of work done or materials furnished pursuant
to the contract is:
__________________________________________
__________________________________________
7. The names and addresses of all persons, if any,
who hold an interest or estate with the owner as joint tenants
or as tenants in common are:
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
8. The full names and full addresses of the predecessors
in interest of the owner if the property was transferred
after the work or improvement referred to in this notice
began:
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
__________________________________________
__________________________________________
__________________________________________
(Name/Address)
9. The work of improvement, described in Paragraph
6, on the property was completed on ______________ (date).
Dated: __________________
__________________________________________
(Owner's Name)
By________________________________________
(Signature)
VERIFICATION
I,
the undersigned, say:
I
am the ____________________________________________
(Owner, officer of owning entity, agent of owner, etc.)
of
the interest or estate, described in Paragraph 3, of the
property, described in Paragraph 4;
I
have read the foregoing notice and know and understand the
contents of it, and the facts stated in it are true and
correct.
I
declare under penalty of perjury that the foregoing is true
and correct.
Executed
on ____________________________, ______, (date)
at
____________________________________________
(Place where signed)
____________________________________________
(Personal signature)
CERTIFICATE OF ACKNOWLEDGEMENT
| STATE
OF CALIFORNIA |
) |
| |
)
ss |
| County
of ____________ |
) |
On __________________ __, 200__ before me, _______________________________________, [name of notary] Notary Public, personally appeared ______________________________________________, [name(s) of signer(s)] who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature : __________________________ (Seal)
CERTIFICATE OF MAILING
I hereby declare that, pursuant to the requirements of Civil Code §3259.5, I sent notification of recordation of the attached Notice of Completion to the below-listed person or entity on _________ ___, 200_. Furthermore, I declare that this notice of recordation was sent by [registered mail, certified mail or first class mail]. The notice of recordation was provided within 10 days of recordation of the Notice of Completion:
_________________________________________
_________________________________________
_________________________________________
(Name/Address from Preliminary 20-Day Notice or from contract with Original Contractor)
I declare under penalty of perjury of the laws of the State of California that the foregoing is true and correct.
Signed at: _________________________________
(Location)
on _______________________________________
(Date)
Signature of person making service
_________________________________________
[It is advisable to use the Postal Service's Return Receipt Requested service. Under Civil Code §3259.5, failure to provide notification of recording of the Notice of Completion within 10 days extends the time within which a mechanic's lien may be recorded or a stop notice served to 90 days beyond the date the Notice of Completion was recorded. Notification is evidenced by a certificate of mailing.]
[Prepare one Proof of Service for each person served.]
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Recorded at the request of
and to be returned to:
(Lien claimant's name, address, city, state, ZIP code)
DESIGN
PROFESSIONAL'S LIEN
NOTICE OF LIEN
(California Civil Code §3081.3)
1.
By this notice, a lien is created in favor of
_________________________________________
(Name of design professional)
in
the amount of
_________________________________________
(Amount of claim of lien)
2. The current owner of record of the real property
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