Lien Claimant:

Property Owner:

Property Description: Land and buildings located at _________________________________ in

______________________, Maine, being further described in the _______________________

County Registry of Deeds in Book __________, Page ____________.

Amount Due:

I, _______________________________________________, designated broker of

_________________________________________, known as lien claimant, being first duly sworn, claims a lien on the above property for labor performed, said labor furnished with the full knowledge and consent of the owners of said property. The first date of furnishing labor was

___________________________ and the last date was ________________________________.

STATE OF MAINE

COUNTY OF                   ,ss.                           , 199

     Personally appeared the above named _________________________________________

and made oath to the truth of the facts contained herein.