Fill and Sign the Lien Statement Subcontractorsupplier Corporation Form

Lien Statement – Subcontractor/Supplier Page 1 of 2 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 – SUBCONTRACTOR/SUPPLIER -- CORPORATION Kan. Stat. Ann. § 60 -1103 COMES NOW, ___________________________ ____________________, as a representative of _________________________ a ____________________ corporation acting in the capacity of a subcontractor, supplier, or other party furnishing labor, equipment, material, or supplies used or consumed for the improv ement of real property under an agreement with the contractor, 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. Said labor and/or materials were provided un der agreement with contractor, _______________________________________. 4. The undersigned last furnished labor and/or materials for the improvement of the above named property on or about the ____ day of ______________, 20___. This the ______ day of ____ ______________, 20____. ______________________________ Signature ______________________________ Title ______________________________ Corporation Lien Statement – Subcontractor/Supplier Page 2 of 2 Verification State of KANSAS County of ________________________ Signed and sworn to (or affi rmed) 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 ___________________ Th is 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