Fill and Sign the 38 22 109 Form

Notice of Lien Claim Page 1 of 2 Prepared by, recording requested by and return to: ---------------------- Above this Line for Official Use Only --------------------- Name: __________________ Company: ___________________ Address: _____________________ City: ______________________ State: _____ Zip: __________ Phone: ________________________ Fax: _______________________ NOTICE OF LIEN CLAIM — INDIVIDUAL (Colorado Revised Statute §38 -22 -109(10)) Comes now, (Name) __________________________________ , (Address) ________________________________ ________________________________ , (Telephone Number) _________________________ , and hereby provides notice of the following: 1. The undersigned has performed labor, or supplied materials or laborers, for the purposes of improvements of proper ty located at: ____________________________________________________________ ___________________________________________________________ , and is entitled to a lien thereby. 2. Said improvements were the result of a contract entered into between the undersigned and ___________________________________________ . 3. That the undersigned he reby reserves the right to file a lien statement regarding said improvements within four months after completion of improvements or six months after the date of filing of this notice, whichever occurs first. This the _____ day of _________________ , 20 _____ . _________________________ Signature _____ ____________________ Print or Type Name Notice of Lien Claim Page 2 of 2 STATE OF COLORADO COUNTY OF _____________________ The foregoing in strument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ CO § 38 -22-109(10)