TO: ____________________ (name of owner)

_____________________________

_____________________________ (address)

Notice is hereby given that the undersigned, _____________________ (name) intends to file a mechanic’s lien for _______________ (amount) , on real property owned by you and commonly known as _________________________ (street address). The legal for said property is as follows: _____________________________________________________________

The filing of said lien, pursuant to __________________ (cite statute), is for the purpose of securing payment of amounts due for ___________________ (services) performed by the undersigned within the last _________ (number) days, in accordance with the _____________________ (written or oral) agreement entered into on __________ (date) between you and the undersigned.

Date________________

__________________________

(Signature)