Fill and Sign the Co Notice Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _______________________ Company: ___________________ Address: _____________________ City: _______________________ State: _____ Zip: _________ Phone: _______________________ Fax: _______________________ DISBURSER'S NOTICE-INDIVIDUAL (Colorado Revised Statute § 38-22-126) BE IT KNOWN that [name] ___________________________________ , [Address and phone number] ________________________________________________________________ , _____________________ , has agreed to disburse funds to principal contractor, [name] ____________________________________ , [Address and phone number] _______________________________________________________________________ , _______________________ , for improvements to property located at [address] _______________________________________________________________ , and described as [legal description] ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ , and owned by [name] _________________________________ , [Address and phone number] ________________________________________________________________ , ________________________ . This the _____ day of _______________ , 20 _____ . ________________________ Signature of Disburser _____ ___________________ Print Name Disburser’s Notice Page 1 of 2 STATE OF COLORADO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ CO § 38-22-126 Disburser’s Notice Page 2 of 2