Fill and Sign the Ak Company Form

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 NONRESPONSIBILITY—CORPORATION, LLC, etc. (A.S. § 34.35.065) COMES NOW, ________________________________ , as a representative of ___________________________________ a __________________________________ company which is an owner or a party having or claiming an interest in the property undergoing improvement at _________________________________ , and would state as follows: 1. On or about the ____ day of ____________________ 20 _______ , the undersigned corporate owner or party in interest obtained knowledge of the construction, alteration, or repair taking place at the above-described property, and 2. Notice is hereby given that the undersigned will in no way be held responsible for the cost of said improvements or subject to a lien therefore. This the _____ day of _____________ , 20 ______ . Notice of Nonresponsibility Page 1 of 2 _________________________ Name of Corporation By: __________________________ ______ _ _____ Signature Title _________________________ Type or Print Name Attest: Secretary State of Alaska _________________ Judicial District (or County of _______________) The foregoing instrument was acknowledged before me this _____________________ day of ______________, 20___, by _____________________________ (signing party), the ____________________________ (title) of ________________________________ (name of company) a ____________________________ (state of incorporation) company, on behalf of said company. ________________________________ Notary Public Print Name _______________________ Serial Number, if any: _______________ My commission expires: Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service with signed receipt ( ) Mailing a true and correct copy of same by first-class U.S. mail, postage prepaid, return signed receipt requested to ___________________________, So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Nonresponsibility Page 2 of 2