AFFIDAVIT OF OWNER RE: LIEN RIGHTS

STATE OF
                                    ss.
COUNTY OF              

    The undersigned, being first duly sworn, deposes and says that they are the owner of the following described property in ______________________ County, ________________State, described as follows:

     
     More commonly known as:  

    Tax I.D. No:

    (COMPLETE THIS AFFIDAVIT BY CHECKING THE APPROPRIATE BOX BELOW)

Deponent further says that:
__________ A.   There have been no repairs, alterations, remodeling or new construction on the 
                            above described premises in the last ninety (90) days.

__________ B.   Deponent has contracted for repairs, alterations, remodeling or new construction
                           on the above described premises which have been completed within the last ninety
                           (90) days,  Deponent paid for all of said improvements directly to the contractors
                           and there are no unpaid bills or claims for labor or services or material in con-
                           nection therewith except as follows: ______________________________________                        
                           _____________________________________________________________________
                            _____________________________________________________________________

__________ C.   Deponent has contracted with a general contractor for repairs, alterations, remod-
                            eling or new construction on the above described premises which have been com-
                            pleted within the last ninety (90) days.  The sworn statement of said contractor for
                            improvements, and appropriate supporting waivers of lien, are submitted herewith.
                            Deponent has not been served with any notice that a lien will be claimed on the 
                            above described premises for labor performed or material furnished except as 
                            follows: ______________________________________________________________
                            _____________________________________________________________________
                            _____________________________________________________________________

__________  D.   Deponent has not other liens on said property other than those described here:
                           ______________________________________________________________________
                           ______________________________________________________________________

DATED:________________________________   SIGNED BY:
                                                                                  ____________________________
                                                                       
                                                                                  ____________________________

Subscribed and sworn to before me this  __________ day of ____________, 20__.

Commission Expires: ______________      __________________________________
                                                                        Notary Public