Fill and Sign the Kansas Intent Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: NOTICE OF INTENT TO PERFORM—CORPORATION (Kan. Stat. Ann. § 60-1103b) I, _______________________________________, (name of supplier, subcontractor or contractor) whose address is ___________________________________ _____________________________________________, do hereby give public notice that I am a supplier, subcontractor or contractor or other person providing materials or labor on property owned by _____________________________________, and having the legal description as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ . [Legal Description of Property] This the ____ day of ____________________, 20____. ______________________________ Signature ______________________________ Title ______________________________ Corporation Notice of Intent to Perform Page 1 of 2 STATE OF KANSAS COUNTY OF ___________________ This instrument was acknowledged before me on __________________________ (date) by ___________________________________________ [name(s) of person(s)] as _____________________________________________________ (type of authority, e.g., officer, trustee, etc.) of _____________________________________ (name of party on behalf of whom instrument was executed.) _____________________________ Notary Public Print Name: ___________________ My commission expires: _____________________ Notice of Intent to Perform Page 2 of 2