Fill and Sign the Kentucky Owner Form

NOTICE TO OWNER -INDIVIDUAL (K.R.S.A. § 376.010(3)) COMES NOW, __________________________________ , of the following address _______________________________________________________________ , and would state as follows: 1. The undersigned ( ) has furnished ( ) will furnish labor or materials for the improvement of the property located at _________________________________________________________________ . 2. The above-mentioned property is owned by ______________________________ . 3. The value of the labor and/or materials in full, with all credits and setoffs known to the undersigned, is $ ____________ . 4. The above-mentioned labor and/or materials were not furnished by the undersigned under a direct contract with the property owner or his agent. 5. Labor and/or materials were last provided on the _____ day of _____________ , 20 ______ , said date being within seventy-five (75) days of the date of this notice on claims less than $1,000, or within one hundred twenty days (120) of the date of this notice on claims in excess of $1,000. 6. The undersigned is entitled to a lien for the above amount. ______________________________ Signature _____ _________________________ Type or Print Name Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ the property owner at his/her last known address, or to his/her duly authorized agent 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 to Owner Page 1 of 1