Fill and Sign the Kentucky Notice 497307900 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 FURNISHING –CORPORATION Professional Engineers, Land Surveyors, Licensed Architects and Landscape Architects. (K.R.S.A. § 376.075) COMES NOW, ________________________________ , as representative of ________________________________ a _________________________________ corporation, which may served at the following address _______________________________________________________________________ , and would state as follows: 1. The undersigned corporation has performed professional services as a professional engineer, land surveyor, licensed architect, or landscape architect for the improvement of the property located at _______________________________________________________________________ and described as _______________________________________________________________________ . 2. The above-mentioned property is owned by _________________________________ . 3. The value of the services performed, with all credits and setoffs known to the undersigned corporation, is $ ______________ . 4. The above-mentioned services were provided by the undersigned corporation under contract directly with the ( ) property owner, or his agent, ( ) a contractor, ( ) an architect. 5. The undersigned corporation ceased providing services on the _____ day of _____________ , 20 ______ , said date being within six (6) months of the date of the filing of this Notice. 6. Pursuant to Kentucky Revised Statute Annotated § 376.075, the undersigned is entitled to a lien for the above amount. Notice of Furnishing Page 1 of 3 ______________________________ Signature _____ _________________________ Type or Print Name _____ _________________________ Title _____ _________________________ Corporation Attest: Secretary State of Kentucky County of __________________ The foregoing instrument was acknowledged before me this _________________ (date) by ___________________________________________ (name of officer or agent, title of officer or agent) of _____________________________________ (name of corporation acknowledging) a ____________________________________ (state or place of incorporation) corporation, on behalf of the corporation. ______________________________ Notary Public Title (and Rank): _______________ Print Name: ___________________ (Serial number, if any)___________ (Seal, if any) My commission expires: _____________________ Notice of Furnishing Page 2 of 3 Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Regular Mail ( ) Registered Mail ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to ____________________________. So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Furnishing Page 3 of 3