Notice is given that _________[employee], who resides at _________[address], _________[city], _________[county], _________[state], ("employee"), claims a lien against the property of _________[employer], of _________[address], _________[city], _________[county], _________[state], ("employer"). The property against which the lien is claimed is located at _________[address], _________[city], _________[county], _________[state].

Employer employed employee on [date] to perform the following work: _________. Pursuant to [oral] [written] contract with employer, employee performed the described work and was to have been paid $_____ per [hour] [week] [other]. Employee worked a total of _________[number] _________[hours, weeks, etc.] from [date] to [date], for which employee has not been compensated. After deducting all just credits owed by employee to employer, the amount still unpaid and owing from employer to employee is $_____.

Pursuant to _________[statute] [employee employment contract] [other], employee claims a lien of $_____ on the property described above.

[Acknowledgment or verification]