Fill and Sign the Demand of Supplier of Materials Machinery Tools Laborers or Services for Information Regarding Owner Disburser and Principal

DEMAND OF SUPPLIER OF MATERIALS, MACHINERY, TOOLS, LABORERS, OR SERVICES FOR INFORMATION REGARDING OWNER, DISBURSER AND PRINCIPAL CONTRACTOR - INDIVIDUAL (Colorado Revised Statute §38-22-126(3)) COMES NOW, __________________________________ , the undersigned from whom ___________________________________ has ordered or contracted for labor, services, machinery, tools, equipment, laborers, or materials to be used in the improvement of property and demands a statement of the following information from __________________________________ , who has ordered or contracted with the undersigned as described above: 1. T he name, address, and telephone number of the owner or reputed owner of the land to be improved; 2. The name, address and telephone number of the principal contractor, if any; 3. The name, address and telephone number of the disburser, if any; and 4. A legal description or the address, if any, of the land to be improved. This the _____ day of _________________ , 20 _____ . _________________________ Signature _____ ____________________ Print or Type Name Demand of Supplier of Materials Page 1 of 2 STATE OF COLORADO COUNTY OF ____________________ In _______________, on the _____ day of ____________, 20___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed. Type of ID Produced: _________________________ Affiant __ is __ is not personally known to me _______________________________ NOTARY PUBLIC My Commission Expires: _____________________ (SEAL) CO § 38-22-126(3) Demand of Supplier of Materials Page 2 of 2