Fill and Sign the Federal Notice of Traumatic Injury and Claim for Continuation Form

Stop Payment Notice Page 1 of 4CA Civil Code § 8502 STOP PAYMENT NOTICE (Individual as Claimant) Name of Party Giving Notice: Street Address: City, State and Zip Code: Relationship to other parties: Statement re Nature of work provided: Person/Party to whom work provided: Claimant’s Estimate of total amount in value of the work to be provided: $ Claimant’s Demand for unpaid work through date of this notice: $ Name of owner or reputed owner: Street Address: City, State and Zip Code: Name of direct contractor: Street Address: City, State and Zip Code: Name of construction lender: Street Address: City, State and Zip Code: Site of the Improvement: Street Address: City, State and Zip Code: Legal Description: Stop Payment Notice Page 2 of 4CA Civil Code § 8502Date: Signature Print or Type NameI, , declare under penalty of perjury under the laws of the State of California, that I have read the above STOP NOTICE, and I know it is true of my own knowledge, except as to those things stated upon information and belief, and as to those I believe it to be true. Executed , 20 , at , . Declarant Type or Print Name Note: CA Civil Code §8506 provides that a Stop Notice:1. To an Owner shall be given to the Owner or the Owner’s architect;2. To a Construction Lender to the manager or other responsible party at the office or branch of the lender administering or holding the construction funds. Stop Payment Notice Page 3 of 4CA Civil Code § 8502 PROOF OF NOTICE DECLARATION (Civil Code § 8118) I, , declare that I have served copies of the Above by (check appropriate box below):a. By personally delivering copies to:Name: Title: At: Street Address: City, State and Zip Code: On: , 20 , at am / pm. b. By Certified, Express, or Registered Mail Service, postage prepaid addressed to: Name: Title: At: Street Address: City, State and Zip Code: On: , 20 , at am / pm. See attached documentation provided by the US Postal Service or express mail service showing the date of delivery and the name of the person accepting delivery; tracking record or other documentation from express carrier showing attempted delivery or delivery of the notice; or, in the event of non-delivery, the returned envelope itself.I declare under penalty of perjury that the foregoing is true and correct. Signed at , California , on , 20______.Signature Print or Type Name ATTACH SERVICE LIST OF CERTIFIED OR REGISTERED MAIL WHEN RETURNED, OR PHOTOCOPY OF POST OFFICE RECORD OF DELIVERY OF RECEIPT. Stop Payment Notice Page 4 of 4CA Civil Code § 8502A notary public or other officer completing the certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.State of California County of On ______ before me, ______________(here insert name and title of the officer), personally appeared _______________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.WITNESS my hand and official seal.Signature ____________________________ (Seal)