Fill and Sign the Nature of Document Notice of Claim of Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: _____________________ Address: ____________________ City: __________________ State: _____ Zip: __________ Phone: ________________ Fax: _________________ Nature of Document: Notice of Claim of Lien 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 1 of 2 This the _____ day of _____________ , 20 ______ . _______________________ Signature _____ __________________ Type or Print Name Acknowledgment of Individual State of Utah County 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 Public My commission expires:             Type or Print Name Residing at:       Notice of Claim Page 2 of 2