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Fill and Sign the Minnesota Department of Human Services Contract for Form

Fill and Sign the Minnesota Department of Human Services Contract for Form

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Notice of Requested Information Page 1 of 2 Notice of Requested Information-Individual (A.C.A. § 18-44-108) COMES NOW, _________________________________, a contractor or subcontractor performing improvements on property at _______________________________________, and would state as follows:1.On or about the _____ day of __________, 20 ______, a request for information pursuant to Arkansas Code Annotated § 18-44-108 was received by the undersigned.2.The following is a list of all parties that have furnished labor or materials and are due the following amounts:Party Supplying Amount due__________________________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________. 3.The undersigned hereby certifies that the owner of the above mentioned property undergoing improvements has received a preliminary notice pursuant to §18-44-115 of the Arkansas Code Annotated. This the _____ day of ___________, 20_____ . _________________________ Signature_________________________Print or Type Name Notice of Requested Information Page 2 of 2STATE OF ARKANSAS COUNTY OF _________________ On this the ____ day of __________, 20__, before me, ____________________, the undersigned officer, personally appeared__________________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal on this ____ day of ______, 20___. ___________________________ NOTARY PUBLIC My Commission Expires:____________________ AK § 18-44-108

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