Fill and Sign the Delaware Corporation Form

STATEMENT OF CLAIM— CORPORATION (DE §2712) COMES NOW, the undersigned representative of ____________________________ _______ , a ____________________________ ______ corporation, as plaintiff/claimant, having provided materials or labor for the improvement of the below-described structure, and files this Statement of Claim, and in support thereof would state as follows: 1. The name of the corporation that provided materials or labor is _______________________________________ . 2. The owner or reputed owner of the structure improved is ___________________________________ . 3. The contractor on the project is ______________________________________ . 4. The undersigned provided labor or materials under a contract with: ( ) the property owner, ( ) the owner’s agent, or ( ) the contractor. Statement of Claim Page 1 of 4Tax Parcel Identification Number (if applicable) _____________________ Prepared by, recording requested by and return to: Name: ___________________ Company: _____________________ Address: _____________________ City: _______________________ State: _____ Zip: __________ Phone: _______________________ Fax: __________________________ 5. Labor and/or materials began being furnished on ____________________________________ . 6. Labor and/or materials ceased being furnished on __________________________________ . 7. The structure being improved is located at: __________________________________ . 8. The labor and/or materials provided were furnished on the credit of the above-mentioned structure. 9. The undersigned corporation has a claim for the amount of _____________________________________________________ ($ _______________ ), such amount being in excess of twenty-five dollars ($25.00) , and that neither this amount nor any part thereof has been paid to the undersigned; and 10. The amount that is due to the undersigned on each structure is _____________________________________________________ ($ _______________ ). 11. A first mortgage, or a conveyance in the nature of a first mortgage was recorded on ___________________________________ , and was granted to secure an existing indebtedness or future advance provided at least 50% of the loan proceeds are used for the payment of labor or materials, or both. This the _____ day of ______________ , 20 _____ . _____ ___________________________ Name of Corporation By: _____ _________________________ Signature Title _____ ____________________________ Type or Print Name Statement of Claim Page 2 of 4 Attest: ___________________________ Secretary STATE OF DELAWARE COUNTY OF ________________ Before me, _____________________________, a Notary Public in and for the County of _______________, State of Delaware, personally appeared _________________________, in an official capacity as ______________________, of _________________________corporation, who being duly sworn, doth depose and say: That he has personal knowledge of the facts set forth in the foregoing Statement of Claim, and that the same are true and correct to the best of his knowledge and belief. ______________________________ Affiant Signed and sworn to (or affirmed) before me on _________________________ by ______________________________________ [Person(s) making statement]. ________________________ Signature of Notarial Officer ________________________ Print Name ________________________ Title and Rank SEAL (if any) My commission expires: ____________________ Statement of Claim Page 3 of 4 DE Tit. 25, § 2712(b) Statement of Claim Page 4 of 4