Fill and Sign the Colorado Lien Statement Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ________________________ Company: ____________________ Address: _____________________ City: ________________________ State: _____ Zip: _______ Phone: ________________________ Fax: _________________________ LIEN STATEMENT—Corporation or LLC (Colorado Revised Statute §38-22-109(1)) State of Colorado, County of _____________________ , ss: ___________________________________ , as ________________ of ___________________________________ , a _________________________________ corporation, whose address is _____________________________________ , Colorado, _________ , being first duly sworn, hereby states that: __________________________________ , the lien claimant, hereby asserts a lien against the property located at _______________________________________________________________________ , for laborers and materials that were furnished, or labor performed by ___________________________________ , in furtherance of improvements on said property. The owner or reputed owner of said property, if known, is ____________________________________ . If the lien claimant is a subcontractor or an assignee of a subcontractor, the name of the contractor, if known, is _________________________________________ . The amount due or owing the lien claimant is $ _____________________ . Lien Statement Page 1 of 2 Attached is a copy of the Affidavit of Service of Notice of Intent to File Lien Statement, which states that the Notice was filed at least ten (10) days before the filing of this Lien Statement. The Affidavit should be filed for record with this Lien Statement pursuant to Colorado Revised Statute §38-22-109(3) . This the _____ day of ___________ , 20 ______ . _________________________________________ Name of Company By: __________________________ ______ _ _____ Signature Title ____________________________________ Type or Print Name Attest: Secretary I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Lien Statement are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF COLORADO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____ day of __________, 20____ by ___________________________(name of officer or agent, title of officer or agent) of ___________________________(name of company acknowledging) a __________________ (state or place of incorporation) business entity, on behalf of the company. ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ Lien Statement Page 2 of 2