§ 29-10-104 — Form for lien statement

Wyoming § 29-10-104

• Jurisdiction: Wyoming
• Title 29: Liens
• Ch. 10: FORMS

Text

(a) The lien statement shall be filed with the county
clerk's office in the county where the property against which
the lien is filed is located and shall be completed in
substantially the following form:
Note to lien claimant: This form, if filled out correctly and
filed with the county clerk's office within the time periods
specified in W.S. 29-2-106 constitutes prima facie evidence that
you have provided the content of the lien statement required by
W.S. 29-1-312(b) and (f). If you have any questions regarding
how to fill out this form or whether it has been filled out
properly, you should consult an attorney.
STATE OF _____________ )
) ss.
COUNTY OF _____________ )
LIEN STATEMENT
Pursuant to the provisions of W.S. 29-1-312 relating to lien
statements, the undersigned hereby files this lien statement and
swears as follows:
1. Name and address of lien claimant:
______________________________
______________________________
______________________________
______________________________
______________________________
2. The amount claimed to be due and owing: $____________, plus
pre-judgment interest at a rate of _____% (if applicable), and
attorneys' fees and costs incurred by lien claimant in the
collection of this amount.
3. The names and addresses of the persons against whose
properties the lien is filed include:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
4. An itemized list setting forth and describing the work
performed or materials furnished by the lien claimant:
The amounts due and owing from ________________________ for the
work performed and/or materials provided are set forth in the
actual invoices, or if no invoices exist, then a summary,
attached hereto as Exhibit "A".
5. The name of the persons whom the lien claimant asserts
is/are obligated to pay the debt secured by the lien:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
6. The lien claimant last performed work, or furnished
materials, for which the lien claimant asserts a lien on the
______ day of ______________, 20___.
7. The legal description of the real property where the lien
claimant performed work or furnished materials is set forth in
Exhibit "B", attached hereto.
8. A true and accurate copy of the written contract, if
available, under which the lien claimant performed work or
furnished materials is attached hereto as Exhibit "C". If the
contract was oral or is too extensive, the parties to the
contract and contract terms are described below:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
A copy of the written contract, if applicable, is located at the
following address:
______________________________
______________________________
______________________________
______________________________
______________________________
DATED this ______ day of ______________, 20___.
Name of lien claimant: ______________________________
By: ______________________________
Signature: ______________________________
Title: ______________________________
Note to Notarial officer: If the lien claimant is a legal
entity formed under Title 17 of the Wyoming Statutes or other
applicable law, use the first jurat. If the lien claimant is an
individual or sole proprietor, use the second jurat.
(Alternative 1:)
STATE OF __________________ )
) ss.
COUNTY OF __________________ )
On this _____ day of ______________, 20___, subscribed and sworn
to before me personally appeared ______________________________
(name of signatory), to me personally known, who has read the
foregoing Lien Statement and knows the contents thereof and the
facts are true to the best of his/her knowledge, and being by me
duly sworn, did state that he/she is the
______________________________ (title, position or type of
authority granted by lien claimant) of
______________________________ (lien claimant) and that this
lien statement was signed and sealed on behalf of the lien
claimant by authority granted to the signatory by the lien
claimant.
Witness my hand and official seal.
______________________________
Notarial officer
My Commission Expires:
Seal:
(Alternative 2:)
STATE OF __________________ )
) ss.
COUNTY OF __________________ )
On this _____ day of ______________, 20___, subscribed and sworn
to before me personally appeared ______________________________
(name of signatory), to me personally known, who has read the
foregoing Lien Statement and knows the contents thereof and the
facts are true to the best of his/her knowledge, and being by me
duly sworn, did state that the lien statement to be the free act
and deed of the lien claimant.
Witness my hand and official seal.
______________________________
Notarial officer
My Commission Expires:
Seal: