Fill and Sign the Colorado Corporation Llc 497299966 Form

NOTICE TO DISBURSER BY LIEN CLAIMANT- CORPORATION (Colorado Revised Statute § 38-22-126(4)) Comes now, (Name) _______________________________ , (Address) _______________________________________________________________________ , (Telephone Number) _______________________________ , and hereby provides notice of the following: 1. The undersigned lien claimant is entitled to a lien for labor performed, materials supplied or laborers furnished, for the purposes of improvements of property located at: ___________________________________________________________ and legally described as: ____________________________________________________________ ___________________________________________________________ . 2. Said improvements were the result of a contract entered into between the undersigned and __________________________________ and the terms of the contract include: ____________________________________________________________ ___________________________________________________________ . This the _____ day of _________________ , 20 _____ . _________________________________________ Name of Corporation By: __________________________ ______ _ _____ Signature Title _____ _____________________________________ Type or Print Name CO § 38-22-126(4) Notice to Disburser by Lien Claimant Page 1 of 2 Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service ( ) Leaving a copy at the disburser’s residence or at his place of business with some person in charge located at ____________________________________________. ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to: ________________________________________________________________________ (address) . So certified this the ______ day of ___________________, 20____. ______________________________ Signature Notice to Disburser by Lien Claimant Page 2 of 2