Fill and Sign the Lien Statement Individual Colorado 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--INDIVIDUAL (Colorado Revised Statute §38-22-109(1)) State of Colorado, County of _____________________ , ss: _______________________________________________________________________ , whose address is _______________________________________________________________________ , being duly sworn hereby states that: ______________________________________ , the lien claimant, hereby asserts a lien against the property located at ______________________________________________________________________ , for laborers and materials that were furnished, or labor performed by ______________________________________ , in furtherance of improvements on said property. The owner or reputed owner of said property, if known, is _______________________________________ . If the lien claimant is a subcontractor or an assignee of a subcontractor, the name of the contractor, if known, is ____________________________________ . The amount due or owing the lien claimant is $ __________________________ . Attached is a copy of the Affidavit of Service of Notice of Intent to File Lien Statement, which states that the Notice was filed at least ten (10) days before the filing of this Lien Lien Statement Page 1 of 2 Statement. The Affidavit should be filed for record with this Lien Statement pursuant to Colorado Revised Statute §38-22-109(3) . This the _____ day of ________________ , 20 ______ . _________________________ Signature _____ ____________________ Print or Type Name I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Lien Statement are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF COLORADO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ Lien Statement Page 2 of 2