| NORTH CAROLINA |
___________
COUNTY
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CLAIM OF LIEN |
| 1. |
Name and address
of person claiming the lien:
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| 2. | Name and address of record Owner of the real property claimed to be subject to the lien at the time the claim of lien is filed: |
| 3. | Description of the real property upon which the lien is claimed: |
| 4. | Name and address of the person with whom the Claimant contracted for the furnishing of labor or materials: |
| 5. | Date upon which labor or materials were first furnished upon said property by the Claimant: |
| 5a. | Date upon which labor or materials were last furnished upon said property by the Claimant: |
| 6. | General description of the labor performed or materials furnished and the amount claimed therefor: |
| **IF FILED ON BEHALF OF A SUBCONTRACTOR, ADD THIS PARAGRAPH:** Lien Claimant claims a right of subrogation to the lien held by the General Contractor on the real property. In addition, a copy of the Notice of Claim of Lien served on the Owner pursuant to N.C.G.S. § 44A-18 et seq., with accompanying affidavit of proof of service, is attached hereto as Exhibit A, and Lien Claimant believes that the Owner has or may become personally liable to Lien Claimant by paying funds to the General Contractor following receipt of the Notice of Claim of Lien. | |
| Dated:_________________________ __________________________ | |
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______________________________
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LIEN CLAIMANT
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By: ______________________________
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