Fill and Sign the New York Corporation 497321333 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _________________ Company: _________________ Address: _________________ City: _______________ State: _____ Zip: _______ Phone: _______________ Fax: _______________ Proof of Service of Notice of Lien – Corporation (N.Y. Lien Law § 11-b) COMES NOW, _________________________________ , as a representative of _________________________________ a ________________________________ corporate lienor, whose address is ______________________________________________________________________ , and who has provided labor or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , within five (5) days before or thirty days after filing a Notice of Lien in accordance with N.Y. Lien Law § 10 or filing an Amendment of Notice of Lien in accordance with N.Y. Lien Law § 12-a and states the following: 1. The undersigned lienor filed a Notice of Lien or an Amendment of Notice of Lien on the ____ day of _____________ , 20 ______ . 2. The undersigned lienor served a copy of the Notice of Lien or Amendment of Notice of Lien by certified mail on _________________________________ , the contractor, subcontractor, assignee or legal representative for whom the lienor was employed or to whom the lienor furnished materials, at the following address: ________________________________________________________________________ or if the lienor is a contractor or subcontractor, to ___________________________________ , the person, firm or corporation with whom the contract was made, at the following address: _______________________________________________________________________ . 3. If the undersigned lienor had a direct contractual relationship with a subcontractor or a sub-subcontractor but not with a contactor, the lienor also served a copy of the Notice of Lien or Amendment of Notice of Lien by certified mail to ___________________________________ , the contractor, at the following address: _______________________________________________________________________ . Proof of Service of Notice of Lien Page 1 of 2 This the _____ day of ______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name _____ _________________________ Title _____ _________________________ Corporation Attest: Secretary STATE OF NEW YORK COUNTY OF ___________________ On the ______________ day of ______________ in the year ______________ before me personally came ____________________________ to me known, who, being by me duly sworn, did depose and say that he/she/they reside(s) in ____________________________ (if the place of residence is in a city, include the street and street number, if any, thereof); that he/she/they is (are) the _______________________________________ (president or other officer or director or attorney in fact duly appointed) of the __________________________ (name of corporation), the corporation described in and which executed the above instrument; and that he/she/they signed his/her/their name(s) thereto by authority of the board of directors of said corporation. ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ Proof of Service of Notice of Lien Page 2 of 2