AFFIDAVIT FOR MECHANIC'S AND MATERIALMAN'S LIEN

"NOTICE: THIS IS NOT A LIEN. THIS IS ONLY AN AFFIDAVIT CLAIMING A LIEN."

THE STATE OF TEXAS §

§
COUNTY OF __________ §

BEFORE ME, the undersigned authority, on this day personally appeared ___________________
who upon his oath did depose and state as follows:

"My name is _________________________ and I am a resident of _____________ of

____________________ County, Texas. I am the ________________________ of
_____________________________, a Texas corporation, hereinafter sometimes referred
to as "Claimant", I am over 18 years of age, the facts set forth below are true and correct
and am competent and authorized to make this Affidavit on Claimant's behalf.

Claimant's physical address is ________________________________________

Claimant's mailing address is _______________________________________________.

Pursuant to a Contract by and between Claimant and _____________________________

Claimant has provided _________________________ to improve the real property
described herein. The materials, labor and/or equipment were provided for such
improvement to _______________________. The last known address of
________________________________ is _______________________________. The
project is known as ____________________________ located at
______________________________ in ___________________ County, Texas (tthe
"Project").

The Original Contractor for the improvements for which a lien is claimed is
_____________________, whose last known business address is
____________________________________________.

The Owner or reputed Owner of the real property and of the improvements on which
Claimant asserts a lien is __________________________. Owner's last known business
address is _________________________________.

After allowing all just credits, offsets ________________________ and payments, the
amount of ________________________ /100 Dollars ($_______________) remains
unpaid and said sum is due and owing to Claimant under said Contract. Claimant claims a
lien on said property and improvements under the provisions of Chapter 53 of the Texas
Property Code to secure payment of the above amount. The amount claimed includes
retainage in the amount of $________, which is now due and owing. This amount does
not include any attorneys' fees, interest or costs which may be recovered at law.

The Claimant provided the unpaid labor, material and/or equipment to the Project in the
months of _______________ through ___________________ as follows:

_________ [month, year] $_______________

_________ [month, year] $_______________

 _________ [month, year] $_______________

Total $_______________

The real property sought to be charged with such lien by Claimant is:

[put in address/description]

and more fully described on Exhibit "A" attached hereto and incorporated by reference
herein.

The Claimant sent Notice(s) of the Claim to the Owner or the reputed Owner and to the
General Contractor on ____________________________ by certified mail, return receipt
requested, and by regular first class mail.

One (I) copy of this Affidavit is being sent by Certified Mail, Return Receipt Requested
to the Owner described above, addressed to the Owner's last known address as described
above and one (1) copy of this Affidavit is being sent by Certified Mail, Return Receipt
Requested to the Original Contractor described above, addressed to the Original
Contractor's last known address as described above

SWORN AND EXECUTED on this the _______day of _________________, 20___.

[Claimant company name]

By:____________________________________
Name:_________________________________
Title:__________________________________

THE STATE OF TEXAS §

§
COUNTY OF __________ §

BEFORE ME, the undersigned Notary Public, on this _________ day of _____________________, 20__
personally appeared _______________________________ of _________________________________,
known to me to be the person whose name is subscribed to the foregoing instrument, who acknowledged
to me that such person executed the same for the purposes and consideration therein expressed and in the
capacity therein stated as the act and deed of said [corporation, partnership, etc.] and further swore that
the foregoing was true and correct.

_____________________________________________
Notary Public in and for the State of Texas

AFTER RECORDING RETURN TO

[insert name/company]