Fill and Sign the Nature of Document Notice of Claim Form

Notice of Claim Page 1 of 2Prepared by, recording requested by and return to:Name: ___________________Company: _____________________Address: ____________________City: __________________State: _____Zip: __________Phone: ________________Fax: _________________Nature of Document: Notice of Claim of Lien----------------------Above this Line for Official Use Only--------------------- Notice of Claim – Individual (Utah Code Ann. §38-1-7) COMES NOW, ____________________________________, as a party performing services or furnishing materials or equipment for the improvement of the property located at and described as _______________________________________________________________________, and would state as follows:1.The above-described property is owned by ___________________________, of the following address, if known: _______________________________________________________________________2.The undersigned lien claimant was employed by, or furnished materials or equipment to _________________________________________.3. The undersigned lien claimant first performed labor and/or material on the _____ day of _______________, 20______, and last furnished same on the _____ day of ______________, 20_______, resulting in costs to lien claimant of a total amount of $___________ for labor provided and/or materials furnished.4. The undersigned lien claimant, ________________________________, may be reached at the following address and phone number; _____________________________________________________________________.5.If the lien is on an owner-occupied residence, as defined in Utah Code Ann. §38-11-102, the owner, as defined in Utah Code Ann. §38-11-102, may require the undersigned lien claimant to remove the lien within 15 days in accordance with Utah Code Ann. §38-11-107 by obtaining a certificate of compliance and mailing a copy of the certificate of compliance by certified mail to the undersigned lien claimant at the above address. The 15-day period begins accruing from the date postmarked on the certificate of compliance sent to the lien claimant. Notice of Claim Page 2 of 2 This the _____ day of _____________, 20______. _______________________Signature _______________________ Type or Print Name Acknowledgment of Individual State of UtahCounty of __________________On the ______ day of __________________ , 20______, personally appeared before me ______________________________, the signer of the foregoing instrument, who duly acknowledged to me that he/she executed the same.(Seal)Notary PublicMy commission expires: Type or Print NameResiding at: