NOTICE JEWELER'S LIEN

To: ____________________________ (owner)

____________________________ (address)

____________________________

____________________________

This is to notify that the undersigned, ________________________________________

(jeweler), located at _____________________________________________________

(address), claims a lien on your ____________________________________________

(designate/describe jewelry) _______________________________________________

(add pursuant to ________________________________________ (statute) if statutory authority exists for lien).

The undersigned performed the following duties on the described property: ______________________________________________________ (duties performed). The following items were also supplied by the undersigned in working on the property:

Item Quantity Price

_____________________ _______ $__________

_____________________ _______ $__________

_____________________ _______ $__________

Total $__________

The work was completed on _________________________ (date), and the property remains unclaimed and in the possession of the undersigned.

The undersigned performed the duties _______________________________________

(pursuant to _____________________________ (a written or a oral agreement/contract establishing a price) of __________________ dollars ($__________).

After deducting all offsets and credits, the amount still unpaid and owing, is _________ dollars ($__________).

You may redeem your property by paying the above amount _________________ days after the ________________________ (mailing or posting) of this notice. The property will be sold if it is not redeemed within the specified time. The property will be sold at ____________________________ (place of sale), on _____________________ (date), at _____________________ (time). This will be subtracted from the amount claimed by the undersigned. The costs incurred by the undersigned in the above mentioned process will be deducted from any amount that remains after the lien has been paid. Any remaining amount will be mailed to you at _____________________________ ___________________________________________________________________ (address)

_________________________ _____________________

Signature Date

_________________________ _____________________

Signature Date