Fill and Sign the Ct Corporation Llc 497301008 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _______________________ Company: _____________________ Address: ____________________ City: ________________________ State: _____ Zip: __________ Phone: ______________________ Fax: _______________________ AFFIDAVIT OF ORIGINAL CONTRACTOR – CORPORATION or LLC (Conn. Gen. Stat. § 49-35) BEFORE ME, the undersigned authority, on this day personally appeared __________________________________ , ("AFFIANT") who is personally known to me (or, if not being personally known to me, did confirm his/her identity presenting ___________________________________ as identification (i.e. drivers license #), and appearing to be fully competent and of sufficient age, upon being duly sworn, stated upon Affiant's oath the following: 1. The undersigned, _________________________________ , is a representative of __________________________________ a __________________________________ business entity (corporation or LLC) acting as an original contractor, who may be served with process at the following address _______________________________________________________________________ , and is responsible for the construction, raising, removal, or repairing of a building, or development of a lot or plot of land, and would state as follows: 2. The undersigned corporation began working under a contract for the construction, raising, removal, or repairing of the building, or development of the lot or plot of land described as ________________________________________________________________________ ________________________________________________________________________ on or about the _____ day of _______________ , 20 _____ . 3. Pursuant to Conn. Gen. Stat. § 49-35, the undersigned has recorded this affidavit not later than fifteen (15) days after commencing work, and is therefore entitled to be furnished a copy of any notice of intent to file a lien provided against the above-described property. Affidavit of Original Contractor Page 1 of 2 This the _____ day of _____________ , 20 _____ . ________________________________ Name of Company By: ___________________________________ _____ _ Signature Title ________________________________ Type or Print Name Attest: Secretary Acknowledgment for Corporation State of Connecticut County of ________________________ On this the ______________ day of ______________, ______________, before me, a Notary Public, personally appeared __________________________________________ (Name of Officer) who acknowledged himself/herself to be the ________________________ (Title of Officer) of ____________________________ (Name of Corporation), a corporation, and that he/she, as such ____________________________ (Title of Officer), being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself/herself as ____________________________ (Title of Officer). In witness whereof I hereunto set my hand. Date:___________________________ ______________________________ Notary Public Print Name: ___________________ My Commission Expires: _____________________ Affidavit of Original Contractor Page 2 of 2