REPAIRMEN’S LIEN STATEMENT
Pursuant to K.S.A. § 58-201 et seq .
STATE OF KANSAS )
) ss.
COUNTY OF _____________ )
[Insert Name of Person Signing] of [Insert Name of Company] (“ Dealer ”), being first duly sworn, deposes and states that he/she is the [Insert Title] of Dealer and that Dealer provided services, repairs, equipment, parts and/or materials (collectively, the “ Work ”) for the improvement and repair of [Insert Description of Equipment Repaired], serial number ___________ (the “ Equipment ”), which is owned by [Insert Name of Owner, Not a Renter]
(“ Owner ”), at the direction and request of Owner.
The value of the Work is $_____________. An invoice verifying such value and specifically describing the Work is attached as Exhibit A and is incorporated herein by this reference.
The Work was performed in _______________ County, Kansas. [Note – This Statement must be filed in this
County.] Owner’s residence is [Place an “X” by one of the following] [_] in ____________ County, Kansas or [_] unknown. [Note – If the County of Owner’s residence is known, this Statement must also be filed in that
County.]
[Place an “X” by One of the Following Alternatives]
[_] The Equipment came into Dealer’s possession for the purpose of performing the Work and remains in
Dealer’s possession as of the date hereof.
[_] The Equipment came into Dealer’s possession for the purpose of performing the Work on or about
________________, 20___. The Equipment was continuously in Dealer’s possession from such date until
________________, 20___, a date which is less than 90 days before this Repairmen’s Lien Statement is being filed with the Office of the Register of Deeds.
[_] The Equipment was not in the possession of Dealer for purposes of performing the Work. The last date on which the Work was last performed, material was last furnished in performing the Work or equipment was last replaced, added or installed was __________________, 20___. This date is less than 90 days before this
Repairmen’s Lien Statement is being filed with the office of the Register of Deeds.
[Insert Name of Company]
Signature:
Title:
On this _______ day of _________________________, 20___, before me, the undersigned Notary Public, personally appeared ______________________, known to me to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her own free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal at my office the day and year last above written.
________________________________
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See Attached Invoice.
EXHIBIT A
Invoice
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