Fill and Sign the Formal Notice of Intent to File Lien by Individual Pennsylvania

Formal Notice of Intention to File Claim -- Individual (Pa. Stat. Ann. tit 49, § 1501) COMES NOW, __________________________________ , as a subcontractor who has provided labor and/or materials for the alteration, repair, erection, or construction of the property located at and described as ______________________________________________________________________ , and would state as follows: 1. On or about the       day of _____________ , 20 _______ , the undersigned subcontractor began providing labor and/or materials under an agreement with the improvement’s primary contractor, ________________________________ . 2. The undersigned is entitled to the value of said labor and/or materials provided, to wit: Labor/Materials Furnished Date Furnished Value/Cost ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. The amount due the undersigned is $ ______________ . 4. The undersigned ceased furnishing labor and/or materials on the       day of _____________ , 20 _______ . This the       day of ______________ , 20 ______ . _________________________ Signature _____ ____________________ Type or Print Name Formal Notice of Intention to File Claim Page 1 of 2 Certificate of Delivery I, _____________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: Personal Service Mailing a true and correct copy of same by first class registered or certified U.S. mail, postage prepaid, return receipt requested to __________________________________ . So certified this the _____ day of _____________ , 20 ______ . ________________________ Signature Formal Notice of Intention to File Claim Page 2 of 2