Pursuant to [cite applicable statutory provision], notice is given that _________ claims a lien on _________[describe property] for and on account of _________[describe claim for which lien is sought].

The name of the owner or reputed owner of the property is _________.

The labor, skill and materials [or as the case may be] were expended or furnished on the property between [Date] and [Date].

The rendition of the labor, skill and materials [or as the case may be] so expended or furnished by the claimant was completed on [Date].

_________ days have now elapsed since that time.

The amount claimant demands for the labor, skill and materials [or as the case may be] so expended or furnished is $_____.

No part has been paid except $_____.

There is now due and remaining unpaid, after deducting all just credits and offsets, $_____, in which amount he [or she] claims a lien on the property.

[Any additional statements required by the governing statute.]

_________, Claimant

[Date]

Address of claimant _________

[Verification]