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NOTICE OF UNPAID COMPENSATION (Business Entity as Direct Contractor or Subcontractor) Name of Party Giving Notice:       Street Address:       City, State and Zip Code:       Relationship to other parties:       Name of owner or reputed owner:       Street Address:       City, State and Zip Code:       Name of direct contractor:       Street Address:       City, State and Zip Code:       Name of construction lender:       Street Address:       City, State and Zip Code:       Site of the Improvement: Street Address:       City, State and Zip Code:       Legal Description:       1. Name of individual laborer owed compensation:       Street Address:       City, State and Zip Code:       Total number of straight time and overtime hours worked on each job: Notice of Unpaid Compensation Page 1 of 4 CA Civil Code § 8104 Job A: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       Job B: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       2. Name of individual laborer owed compensation:       Street Address:       City, State and Zip Code:       Total number of straight time and overtime hours worked on each job: Job A: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       Job B: Straight time hours:       Overtime hours:       Amount “Past Due” and owing:       DATE:       Name of Entity:       ATTESTED BY: (if required) A Corporation By:       Signature Signature of authorized signatory             Type or Print Name Type or Print Name       Its:       Position or Rank Capacity of Signatory CA Civil Code § 8104requires service of notice to the laborer; the laborer’s bargaining representative; construction lender, if any; and the owner or reputed owner. Notice of Unpaid Compensation Page 2 of 4 CA Civil Code § 8104 PROOF OF NOTICE DECLARATION (Civil Code § 8118) I,       , declare that I have served copies of the       by (check appropriate box below): a. By personally delivering copies to: Name:       Title:       At: Street Address:       City, State and Zip Code:       On:       , 20       , at       am / pm. b. By Certified, Express, or Registered Mail Service, postage prepaid addressed to: Name:       Title:       At: Street Address:       City, State and Zip Code:       On:       , 20       Exhibit A attached hereto and incorporated by reference for all purposes See attached documentation provided by the US Postal Service or express mail service showing the date of delivery and the name of the person accepting delivery; tracking record or other documentation from express carrier showing attempted delivery or delivery of the notice; or, in the event of non-delivery, the returned envelope itself. I declare under penalty of perjury that the foregoing is true and correct. Signed at       , California , on       , 20 ______ . Signature       Print or Type Name ATTACH SERVICE LIST OF CERTIFIED OR REGISTERED MAIL WHEN RETURNED, OR PHOTOCOPY OF POST OFFICE RECORD OF DELIVERY OF RECEIPT. A notary public or other officer completing the certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. Notice of Unpaid Compensation Page 3 of 4 CA Civil Code § 8104 SWORN TO AND SUBSCRIBED before me on this the       day of       , 20       . Notary Public My Commission Expires:       Notice of Unpaid Compensation Page 4 of 4 CA Civil Code § 8104