Fill and Sign the Non Contractors Notice of Furnishing Individual Massachusetts Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: ____________________ Address: _____________________ City: ___________________ State: _______ Zip: __________ Phone: _________________ Fax: _________________ NON-CONTRACTOR’S NOTICE OF FURNISHING -- INDIVIDUAL (Mass. Gen. Laws Ann. ch. 254 §4) Notice is hereby given that by virtue of a written contract dated the _____ day of __________________ , 20 ______ , between ________________________________ , Contractor (or Subcontractor) and _________________________________ said ________________________________ is to furnish or has furnished labor or material, or both labor and material, or is to furnish or has furnished rental equipment, appliances or tools, in the erection, alteration, repair or removal of a building, structure or other improvement of real property by _________________________________ , Contractor, for ________________________________ , Owner, on a lot of land or other interest in real property described as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________ .[Legal Description of Property] As of the date of this notice, an account of said contract is as follows: 1. Contract Price $ _________________________________ 2. Agreed Change Orders $ __________________________________ (indicate whether addition or subtraction) 3. Pending Change Orders: $ _________________________________ (indicate whether addition or subtraction) 4. Disputed Claims $ _______________________________ (indicate whether addition or subtraction) 5. Payments Received $ _______________________________ The regular mailing address of the party recording or filing this Notice is as follows: _______________________________________________________________________ . This the _____ day of ____________ , 20 _______ . ________________________ Signature ____ ____________________ Type or Print Name State of Massachusetts County _____________ On this _______ day of _________, 20 ___, before me the undersigned notary public, personally appeared ________________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were _________________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he or she signed it voluntarily for its stated purpose. _____________________ Notary Public Print Name: ___________________ My commission expires: ____________________ Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing Notice of Contract, as recorded and filed, to ___________________________________, Owner, by mailing a true and correct copy of same by certified mail, return receipt requested , U.S. mail, postage prepaid to ___________________________, at his/her usual place of business located at ______________________________________. So certified this the ______ day of ___________________, 20____. ______________________________ Signature MA ch. 254, § 4