RECORDING REQUESTED BY

AND WHEN RECORDED MAIL TO

CLAIM OF LIEN

____________________________________ a mechanics' lien claimant doing business as ___________

______________________________ (hereafter referred to as ''Claimant''), claims a mechanics' lien on the real property situated in ___________________________, California (hereafter referred to as ''the real property''), and more particularly described as follows:

The sum of $______________________________, with interest at the rate of _________percent per annum from ______________, is now due Claimant, after deducting all just credits and offsets, for the following labor, services, equipment and/or material furnished by Claimant:

Claimant furnished the foregoing in connection with the following work of improvement, which is located on the real property described above:

The owner or reputed owner of the work of improvement and the real property is ________________________ .

Claimant furnished the above ______________ at the request of ________________________________ pursuant to ____________________________________________

VERIFICATION

I, ___________________________________, declare that:

I am the _______________________ of __________________________________ named as Claimant in the foregoing claim of lien; I am authorized to make this verification for the claimant.

I have read it and know its contents; it is true to my own knowledge and contains, among other things, a correct statement of my demand after deducting all just credits and offsets.

Executed at ______________, California, on ______________________ .

I declare under penalty of perjury that the foregoing is true and correct.

___________________________________________________

State of California

County of ________________________________

On __________________before me, (here insert name and title of the officer), personally appeared __________________, 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)