The undersigned claimant hereby claims a mechanic’s lien under section _______of the Civil Code of the State of _________ and hereby declares the following:

1. That a statement of claimant’s demand, after deducting all just credits and offsets, in the sum of __________ (amount).

2. That the name of the owner [s] or reputed owner [s] of the property is [are]: ________________________________________________________________________

3. A general statement of the kind of work done or materials furnished by claimant, or both is: ________________________________________________________________________

4. That the name[s] of the person[s] by whom claimant was employed or to whom claimant furnished the materials is [are] ________________________________________________________________________

5. A description of the property sought to be charged with the lien is: ____________ ____________________________________________________________________ (enter full legal description here).

Dated: ________________

_______________________

(Signature of Claimant)