Fill and Sign the Connecticut 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 – CORPORATION (Conn. Gen. Stat. § 49-34) COMES NOW, ____________________________________ , as the representative of ____________________________________ a ______________________________ corporation 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 _____ . _________________________________________ Name of Corporation By: ____________________________ _____ Signature Title _____ _____________________________________ Type or Print Name Certificate of Lien Page 1 of 2 Attest: Secretary State of Connecticut County of __________________ On this the ______ day of __________________ , 20 ______ , before me, the undersigned officer, personally appeared __________________ who acknowledged himself to be the __________________ of __________________ , a corporation , and that he, as such __________________ , being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as __________________ . In witness whereof I hereunto set my hand. Notary Public/ Commissioner of the Superior Court My commission expires:             Type or Print Name 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