Fill and Sign the Notice Nonpayment Tennessee 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 -- Corporation (Tenn. Code Ann. § 66-11-145 ) To: ______________________________ (Contractor contracting with Owner) Address: ______________________________ ______________________________ ______________________________ ______________________________ (Owner) ______________________________ ______________________________ ______________________________ Pursuant to Tennessee Code Annotated § 66-11-145, ______________________________ , as a representative of ________________________________ a __________________________ corporate lienor hereby provides notice that the 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 _____ ____________________ Title _____ ___________________ Corporation Attest: Secretary 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, ___________________________________ of the state and county mentioned, personally appeared ___________________________________ , with whom I am personally acquainted (or proved to me on the basis of satisfactory evidence), and who, upon oath, acknowledged such person to be president (or other officer authorized to execute the instrument) of ___________________________________ , the within named bargainor, a corporation, and that such president or officer as such __________________________________ , executed the foregoing instrument for the purpose therein contained, by signing the name of the corporation by himself/herself as such officer. Witness my hand and seal, at office in _____ , this __________ day of ______ . Notary Public My commission expires:       Notice of Nonpayment Page 2 of 3 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 ______ . Signature       Type or Print Name Notice of Nonpayment Page 3 of 3