Affidavit Claiming a Lien Form

							                            AFFIDAVIT CLAIMING LIEN
STATE OF TEXAS:
COUNTY OF:

NOTE: THIS IS NOT A LIEN. THIS IS ONLY AN AFFIDAVIT CLAIMING A LIEN.

BEFORE ME, a notary public in and for the State of Texas, on this day personally appeared the
undersigned, who being by me duly sworn, on oath states:

   1.     My name is _______________, I am the _____________ (partner, president, credit manager, etc.)
          of _______________ ("Claimant") and am authorized to make this affidavit on its behalf as the
          sworn statement of its claim.

   2.     Claimant furnished labor and/or materials for the improvement of the following described
          land in ___________________ County, Texas:


   3.     The name and last known address of the person to whom the labor and/or materials were
          furnished for such improvement is:

          Name:

          Address:

          The labor and/or material was furnished under a written contract which is attached hereto
          and made a part hereof (if applicable).

   4.     The name and last known address of the original contractor for such improvement is:

          Name:

          Address:

   5.     The name and last known address of the owner or reputed owner of the land and
          improvements thereon is:

          Name:

          Address:

   6.     The   kind   of   work    done   and/or    material  furnished   by     Claimant     is
          ________________________________________________________. Claimant is hereby asserting
          a claim for work performed and/or materials furnished in the following months:
          ___________________.

   7.     The amount unpaid for such work and/or materials and which is now due and owing to
          claimant is $_______________, which amount is true, correct, and just, with all just and lawful
          offsets, payments, and credits known to affiant allowed.

   8.     Claimant's name is ______________ and its mailing address (and physical address, if
          different) is _______________________.
THIS IS A 2-PAGE FORM.