Fill and Sign the Notice Nonpayment Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: ___________________ Address: ___________________ City: ___________________ State: _____ Zip: __________ Phone: ________________ Fax: ________________ Reference Instrument Number: ________________ Map Parcel No. ________________________ This instrument was prepared by: Name: ___________________________________ Address: _______________________________________________________________ Notice of Nonpayment -- Individual (Tenn. Code Ann. § 66-11-145 ) To: ______________________________ (Contractor contracting with Owner) Address: ______________________________ ______________________________ ______________________________ ______________________________ (Owner) ______________________________ ______________________________ ______________________________ Pursuant to Tennessee Code Annotated § 66-11-145, notice is hereby given that ______________________________ (lienor) has not been paid for certain labor, materials, services, equipment, or machinery it supplied in the _______________________________________________________________________ (description of work) of the ________________________________________________ (description of project), located at ______________________________________________________________________ (description of property), and lienor would state the following: Notice of Nonpayment Page 1 of 3 1. The amount presently due and owing is $ __________________ . The last date labor, materials, services, equipment, or machinery were provided in connection with the improvement was ______ day of __________________ , 20 ______ . 2. You may send any communications regarding this matter to the following name and address: ____________________________________________________________ . This the ______ day of __________________ , 20 ______ , Signature of Lienor       Type or Print Name State of Tennessee County of __________________ Personally appeared before me, the undersigned, a Notary Public within and for said State and County aforesaid, duly commissioned and qualified, ________________________ , the within named bargainers, with whom I am personally acquainted, or proved to me on the basis of satisfactory evidence, and who acknowledged that they executed the foregoing instrument for the purposes therein contained. Witness my hand and seal at office this ______ day of __________________ , 20 ______ . Notary Public My commission expires:       Type or Print Name Certificate of Delivery I, ______________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to ______________________________ by: ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested to ____________________________________ . So certified this the ______ day of __________________ , 20 ______ . Notice of Nonpayment Page 2 of 3 Signature       Type or Print Name Notice of Nonpayment Page 3 of 3