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Fill and Sign the Georgia Notice Contractor Form

Fill and Sign the Georgia Notice Contractor Form

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Prepared by, recording requested by and return to: Name ______________________ Address _________________________ City _________________________ State _____________ Zip _____________ Phone ______________________ ------------------------------------Above this line for Official Use Only ----------------------------------- NOTICE TO OWNER AND CONTRACTOR - CORPORATION STATE OF GEORGIA COUNTY OF ____________________ BE IT KNOWN THAT _____________________________________________ , an entity having a right to a lien on the property described below who does not have privity of contract with the contractor and is providing labor, services, or materials for the improvement of property , files this NOTICE TO OWNER and CONTRACTOR and upon being duly sworn states on oath as follows: 1. This Notice is given to the owner or the agent of the owner and to the contractor at the addresses set forth in the Notice of Commencement. 2. The name, address, and telephone number of the person providing labor, services, or materials and filing this Notice is: _________________________________________ _________________________________________ _________________________________________ 3. The name and address of each person at whose instance the labor, services, or materials are being furnished: _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Notice To Owner and Contractor Page 1 of 3 4. The name of the project and location of the project set forth in the Notice of Commencement is: __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ . 5. A description of the labor, services, or materials being provided and, if known, the contract price or anticipated value of the labor, services, or materials to be provided or the amount claimed to be due, if any, is: __________________________________________________________________ __________________________________________________________________ _________________________________________________________________ . 6. This Notice is filed within 30 days from the filing of the Notice of Commencement or 30 days following the first delivery of labor, services, or materials to the property, whichever is later. WITNESS my signature on this the _____ day of _________________ , 20 _____ . ____________________________________ Signature Print Name: _____ ____________________ Title: _____ __________________________ Name of Corporation: _____ ____________ Attest: Secretary Affidavit of Service State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ______________________________________ by personal service or by U.S. mail, return receipt requested, in accordance with law, to the owner or the agent of the owner and the contractor at the addresses set forth in the Notice of Commencement, which the names and addresses are as follows: __________________________________ __________________________________ __________________________________ Notice To Owner and Contractor Page 2 of 3 __________________________________ DATED this the ______ day of __________________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name Sworn to and executed in the presence of: _______________________ (Witness) Sworn to (or affirmed) and subscribed before me this ____ day of __________ (month), __________ (year), by _______________________ (name of person making statement). _______ Personally Known _______ Produced Identification Type and # of ID __________________________ ____________________________ (Signature of Notary) (Seal) _____________________________ (Name of Notary Typed, Stamped or Printed) Notary Public, State of Georgia My Commission Expires: ______________ Reference 44 - 14 - 361.5. Notice To Owner and Contractor Page 3 of 3

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