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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 – CONTRACTOR -- CORPORATION Kan. Stat. Ann. § 60-1102 COMES NOW, _______________________________________________, as a representative of ____________________________ a __________________________ corporation furnishing labor, equipment, material, or supplies used or consumed for the improvement of real property under a contract with the property owner, 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. The following is an itemized statement of labor, material, or supplies used or consumed for the improvement of the above-described property: Labor/Material Provided Date Value/Cost ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________________________Total: _________________________ This the ______ day of __________________, 20____. ______________________________ Signature ________________________ Title Lien Statement – Contractor Page 1 of 2 ______________________________ Corporation 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 Corporation 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: _____________________ KS § 58-201 Lien Statement – Contractor Page 2 of 2

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