Fill and Sign the In Repair Construction Form

Notice of Furnishing- Alteration or Repair - Individual (I.C.A. § 32-28-3-1(h)) COMES NOW, _________________________________ , and hereby provides notice of the following: 1. The undersigned has sold or furnished material, labor, or machinery for the alteration or repair of the owner-occupied single or double family dwelling located at: Street Address: ________________________________________________ Legal Description:       2. The above-mentioned material, labor, or machinery, was sold or furnished to __________________________________ , being a contractor, subcontractor, mechanic, or party other than the owner or owner’s representative. 3. The above-mentioned material, labor, or machinery was first furnished on the ______ day of _______________ , 20 ______ , being within thirty (30) days of the delivery of this notice. 4. Pursuant to Indiana Code Annotated § 32-28-3-1(h), the undersigned hereby provides notice to the owner of the property being altered or repaired that the undersigned is entitled to a lien against said property for the value of material, labor, or machinery sold or provided. This the _____ day of _______________ , 20 ________ . Signature       Type or Print Name Notice of Furnishing – Alteration or Repair Page 1 of 3 STATE OF INDIANA ,       County, ss: Before me, the undersigned, a Notary Public in and for said County and State, personally appeared the within named       , who acknowledged the execution of the foregoing Notice of Furnishing – Alteration or Repair for and on behalf of said ________________________ and who, being duly sworn, stated that the representations therein contained are true. Witness my hand and       Seal this       day of       , 20     . Notary Public. Resident of       County. My Commission expires       , 20     This Instrument was prepared by:                   Signature       Print or Type Name Affirmation Statement I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document, unless required by law. Signature Notice of Furnishing – Alteration or Repair Page 2 of 3       Print or Type Name IN § 32-28-3-1(h) Notice of Furnishing – Alteration or Repair Page 3 of 3