Fill and Sign the Notice Furnishing Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: __________________ Company: __________________ Address: ______________________ City: ___________________ State: _______ Zip: __________ Phone: _______________ Fax: ________________ NOTICE OF FURNISHING -INDIVIDUAL (K.R.S.A. § 376.010(2)) COMES NOW, ___________________________________ , of the following address _______________________________________________________________________ , and would state as follows: 1. The undersigned ( ) has furnished ( ) will furnish labor or materials for the improvement of the property located at _______________________________________ and described as _______________________________________________________________________ . 2. The above-mentioned property is owned by _______________________________ . 3. The value of the labor and/or materials in full, with all credits and setoffs known to the undersigned, is $ _____________ . 4. The above-mentioned labor and materials were furnished by the undersigned under contract with ( ) the property owner, ( ) a contractor, ( ) a subcontractor. 5. The undersigned is entitled to a lien for the above amount, said lien being superior to any mortgage or encumbrance created subsequent to the beginning of the labor or the furnishing of the materials, and the lien shall relate back and take effect from the time of the commencement of the labor or the furnishing of the materials. The lien shall take precedence over a mortgage or other contract lien or bona fide conveyance for value without notice, as this Notice of Furnishing statement showing that the undersigned has furnished or expects to furnish labor or materials, and the amount in full thereof, shall be filed in the office of the county clerk of the county wherein the undersigned furnished or expects to furnish labor or materials, before the recording of the mortgage or other contract lien or conveyance. Notice of Furnishing Page 1 of 2 ______________________________ Signature _____ _________________________ Type or Print Name State of Kentucky County of _____________________ The foregoing instrument was acknowledged before me this _________________ (date) by _____________________________________ (name of person acknowledged). ______________________________ Notary Public Title (and Rank): _______________ Print Name: ___________________ (Serial number, if any)___________ (Seal, if any) My commission expires: ____________________ Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________, the property owner at his or her last known address within seven (7) days of filing the statement with the county clerk, by: ( ) Regular Mail ( ) Registered Mail ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to ____________________________. So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Furnishing Page 2 of 2