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Fill and Sign the Indiana Notice 497306774 Form

Fill and Sign the Indiana Notice 497306774 Form

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Notice of Lien- Individual (I.C.A. § 32-28-3-3(a)) State of Indiana County of __________________ COMES NOW _________________________________ of (address) __________________________________ , and hereby provides notice of the following: 1. The undersigned has performed labor or furnished material or machinery for improvements to the property located at (legal description and street address, if any) Street Address:       Legal Description:       2. The above-mentioned property is owned by ___________________________________ of (address) ____________________________________________________________ . 3. The undersigned is entitled to a lien for the value of labor performed or material furnished in the amount of $ _____________ . 4. The undersigned performed labor or furnished material on the _____ day of _____________ , 20 ______ , being within ninety (90) days of the filing of this notice. Signature       Type or Print Name Notice of Lien 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 LIEN 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 Lien Page 2 of 3 Print or Type Name Notice of Lien Page 3 of 3

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