Fill and Sign the Notice Nonresponsibility 497323622 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: _____________________ Address: _____________________ City: _________________ State: _____ Zip: __________ Phone: ________________ Fax: ________________ Name of Claimant: ________________________________ Name of Debtor: ________________________________ Amount of Lien: _________________ Tax Assessor’s Account Number: _________________ Situs Address of Real Property: ________________________________________________________________________ NOTICE OF NON-RESPONSIBILITY – CORPORATION (Or. Rev. Stat. §87.030) COMES NOW, ___________________________________ , as the representative of __________________________________ a _______________________ corporation which owns the property undergoing improvements located at and described as _____________________________________________________________ ____________________________________________________________ (legal description that includes a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition) , and would state as follows: 1. The undersigned property owner became aware that the above- described property was in the process of being improved on the _____ day of _______________ , 20 _____ . 2. The undersigned hereby provides notice that said improvements are not being carried out at the instance of the undersigned owner and that the Notice of Non-Responsibility Page 1 of 2 above-described property shall not be subject to a lien for any labor performed or materials provided. This the _____ day of ______________ , 20 ______ . _____ ____________________ Signature _____ ____________________ Title _____ ____________________ Corporation _____ ____________________ _________________________ Address Attest: Secretary Notice of Non-Responsibility Page 2 of 2