Fill and Sign the Disbursers Notice Individual Form

Disburser’s Notice Page 1 of 2Prepared by, recording requested by and return to:Name: _______________________Company: ___________________Address: _____________________City: _______________________State: _____Zip: _________Phone: _______________________Fax: _______________________----------------------Above this Line for Official Use Only--------------------- DISBURSER'S NOTICE-INDIVIDUAL(Colorado Revised Statute § 38-22-126) BE IT KNOWN that [name] ___________________________________, [Address and phone number]________________________________________________________________,_____________________, has agreed to disburse funds to principal contractor, [name]____________________________________,[Address and phone number] _______________________________________________________________________,_______________________,for improvements to property located at [address]_______________________________________________________________,and described as [legal description] ________________________________________________________________________ _______________________________________________________________________________________________________________________________________________,and owned by [name]_________________________________,[Address and phone number]________________________________________________________________, ________________________. This the _____ day of _______________, 20_____ . ________________________ Signature of Disburser ________________________Print Name Disburser’s Notice Page 2 of 2STATE OF COLORADOCOUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________Notary Public Printed Name: _________________ My Commission Expires: _____________________CO § 38-22-126