Fill and Sign the North Dakota Lien 497317483 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: _____________________ Address: _______________________ City: ____________________ State: _____ Zip: _________ Phone: _________________ Fax: ___________________ MECHANIC’S LIEN -INDIVIDUAL (N.D.S. § 35-27-13) COMES NOW, _________________________________ , as a party which has provided labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , and would state as follows: 1. The undersigned provided labor and/or materials for the improvement of the above-described property under and pursuant to a contract with or at the request of _________________________________ . 2. The name of the owner or reputed owner, if known, of the above-described property is ________________________________ . 3. The undersigned has kept an itemized account of such labor and/or materials, separate and apart from all other items of account against the purchaser, and after deducting all just credits and offsets, is owed the amount of $ _____________ , which the undersigned has not been paid in full. 4. Due and written notice demanding payment of the undersigned’s account for such labor and/or materials has been made upon the owner as provided by law. 5. The undersigned is entitled to a mechanic’s lien and a mechanic’s lien for the undersigned’s account is hereby filed and claimed on the buildings and land described above. This the _____ day of ______________ , 20 _______ . ______________________________ Signature Mechanic’s Lien Page 1 of 2 _____ _________________________ Type or Print Name STATE OF NORTH DAKOTA COUNTY OF __________________ The foregoing instrument was acknowledged before me this _____ day of _______________ , 20 ______ by ___________________________________ (name of person acknowledging). _____________________________ Notary Public Printed Name: _________________ My Commission Expires: ________________ Mechanic’s Lien Page 2 of 2