Fill and Sign the Lien Claimant Furnished or Supplied Labor Form

Assignment of Lien Page 1 of 2 Prepared by, recording requested by and return to: Name: ___________________ Company: ____________________ Address: ______________________ City: ________________________ State: _____ Zip: _________ Phone: _____________________ Fax: _____________________ ----------------------Above this Line for Official Use Only--------------------- ASSIGNMENT OF LIEN- INDIVIDUAL Beginning on or about the _____ of _______________, 20_____, the undersigned lien claimant, __________________________________, furnished or supplied labor, materials, or laborers to ___________________________________ for the purpose of improvements of real property at _________________________________________________________________, such that the undersigned lien claimant is entitled to a lien for the value of labor, materials, or laborers supplied. Notice is hereby given that the above-mentioned lien claimant does hereby assign his or her claim and lien to ___________________________________, who may commence and prosecute the action upon all of the notices of lien in his or her own name or in the name of the original lien claimant. This the _____ day of _______________, 20______. ______________________________ Signature ______________________________ Type or Print Name Assignment of Lien Page 2 of 2 State of Nevada County of _______________ This instrument was acknowledged before me on _____________ by ____________________________________. _________________________ (Signature of notarial officer) (Seal, if any) _________________________ (Title and rank (optional)) (My commission expires (optional): ___________) Certificate of Delivery I, __________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to _______________________________________ by: ( ) Personal Service ( ) 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