(Consult an attorney before using this form or relying on this information)
THIS LEGAL DOCUMENT REFLECTS THAT A CONSTRUCTION LIEN HAS BEEN PLACED ON THE REAL PROPERTY LISTED HEREIN. UNLESS THE OWNER OF SUCH PROPERTY TAKES ACTION TO SHORTEN THE TIME PERIOD, THIS LIEN MAY REMAIN VALID FOR ONE YEAR FROM THE DATE OF RECORDING, AND SHALL EXPIRE AND BECOME NULL AND VOID THEREAFTER UNLESS LEGAL PROCEEDINGS HAVE BEEN COMMENCED TO FORECLOSE OR TO DISCHARGE THIS LIEN.
State of _____
County of _____
Before me, the undersigned notary public, personally appeared _____, who was duly sworn and says that she or he is (the lienor herein) (the agent of the lienor herein _____), whose address is _____; and that in accordance with a contract with _____, lienor furnished labor, services, or materials consisting of _____ on the following described real property in _____ County, Florida:
(Legal description of real property)
owned by _____ of a total value of $_____, of which there remains unpaid $_____, and furnished the first of the items on _____, (year) , and the last of the items on _____, (year) ; and (if the lien is claimed by one not in privity with the owner) that the lienor served her or his notice to owner on _____, (year) , by _____; and (if required) that the lienor served copies of the notice on the contractor on _____, (year) , by _____ and on the subcontractor, _____, on _____, (year) , by _____.
Sworn to (or affirmed) and subscribed before me this _____ day of _____, (year) , by (name of person making statement) .
(Signature of Notary Public – State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known _____ OR Produced Identification _____
Type of Identification Produced_______________