Fill and Sign the Certificate Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ______________________ Company: ____________________ Address: ______________________ City: ______________________ State: _____ Zip: __________ Phone: ____________________ Fax: ________________________ CERTIFICATE OF LIEN – INDIVIDUAL (Conn. Gen. Stat. § 49-34) COMES NOW, _________________________________ , as a party which has performed services or furnished materials for the improvement of the real property described as ________________________________________________________________________ _______________________________________________________________________ , and would state as follows: 1. On or about the _____ day of _______________ , 20 _____ , the undersigned commenced performing services or furnishing materials for the improvement of the above described property. 2. The Owner of said property is __________________________________ . 3. The undersigned is justly due, as nearly as can be ascertained, the amount of $ _________________ for the furnishing of said services, labor, or materials and is entitled to a lien for said amount. This the _____ day of __________________ , 20 _____ . _________________________ Signature _____ ____________________ Print or Type Name Certificate of Lien Page 1 of 2 State of Connecticut County of __________________ On this the ____________ day of _____________________, ____________, before me, ________________________ (name of notary), personally appeared ____________________________________, known to me (or satisfactorily proven) to be the person(s) whose name(s) _________ ( is or are) subscribed to the within instrument and acknowledged that ________________________ (he/she/they) executed the same for the purposes therein contained. In witness whereof I hereunto set my hand. Date:___________________________ ______________________________ Notary Public Print Name: ___________________ My Commission Expires: ____________________ Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and attested copy of the foregoing to ___________________________________ by: ( ) Hand Delivery to the owner or original contractor at his usual place of abode. ( ) Mailing a true and correct copy of same by registered or certified U.S. mail to the owner or original contractor at the place where he resides. ( ) By Publication. ________________________ Signature Certificate of Lien Page 2 of 2