Fill and Sign the Indiana Notice Form

Notice of Furnishing – Original Construction Page 1 of 3 Notice of Furnishing- Original Construction- Individual (I.C.A. § 32-28-3-1(i )) COMES NOW, ___________________________________, and hereby provides notice of the following: 1. The undersigned has sold or furnished material, labor, or machinery for the original construction of a single or double family dwelling located at Street Address: ________________________________________________ Legal Description: for the intended occupancy of the owner upon whose real estate the construction took place. 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 within si xty (60) days of this notice on the _____ day of _______________, 20_______. 4. Pursuant to Indiana Code Annotated § 32-28-3-1(i), the undersigned hereby provides notice to the owner of the property being improved 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 – Original Construction Page 2 of 3 ACKNOWLEDGEMENT 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- ORIGINAL CONSTRUCTION for and on behalf of said ________________________, 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 Notice of Furnishing – Original Construction Page 3 of 3 Affirmation Statement I affirm, under the penalties for perjury, that I have taken reason able care to redact each Social Security number in this document, unless required by law. Signature Print or Type Name IN § 32-28-3- 1(i)