Fill and Sign the Kansas Lien 497307375 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: Company: Address: City: State: Zip: Phone: Fax: LIEN STATEMENT – SUBCONTRACTOR/SUPPLIER -- INDIVIDUAL Kan. Stat. Ann. § 60-1103 COMES NOW, _______________________________________________, as a subcontractor, supplier, or other party furnishing labor, equipment, material, or supplies used or consumed for the improvement of real property under an agreement with the contractor, and would state as follows: 1. The real property undergoing improvement is located at and described as: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. 2. The above-described property is owned by ______________________________. 3. Said labor and/or materials were provided under agreement with contractor, _______________________________________. 4. The undersigned last furnished labor and/or materials for the improvement of the above named property on or about the ____ day of ______________, 20___. This the ______ day of __________________, 20____. ______________________________ Signature Lien Statement – Subcontractor/Supplier Page 1 of 2 Verification State of KANSAS County of ________________________ Signed and sworn to (or affirmed) before me on ___________________________ by _________________________________________ (name(s) of person(s) making statement). ______________________________ (Signature of notarial officer) (Seal, if any) ______________________________ Title (and Rank) My appointment expires: ________ Acknowledgment of Individual STATE OF KANSAS COUNTY OF ___________________ This instrument was acknowledged to me on _______________________________ (date) by ________________________________ [name(s) of person(s)]. ______________________________ Notary Public Print Name: ___________________ My commission expires: ___________________ KS § 58-201 Lien Statement – Subcontractor/Supplier Page 2 of 2