Fill and Sign the Notice of Furnishing of Labor or Materials Individual Form

Notice of Furnishing of Labor or Materials Page 1 of 2 Prepared by, recording requested by and return to: Name: __________________ Company: __________________ Address: ____________________ City: _______________ State: _____ Zip: __________ Phone: _______________ Fax: _______________ ----------------------Above this Line for Official Use Only--------------------- NOTICE OF FURNISHING OF LABOR OR MATERIALS -- INDIVIDUAL (S.D. Codified Laws § 44-9-53) TO CONTRACTOR: _____________________________________________________ (NAME/ADDRESS) AND OWNER: _______________________________________________________________ (NAME/ADDRESS) COMES NOW, ___________________________________, as a sub-contractor or supplier to sub-contractors who has furnished labor and/or materials for the improvement of the property located at and described as _______________________________________________________________________________________________________________________________________________, and would provide notice of the following: 1. The undersigned actually furnished or is scheduled to furnish the first item of labor and/or materials on the _____ day of _____________, 20_______ and ceased, or will cease, providing labor and/or materials for the improvement of the above described property on the _____ day of _____________, 20_______. 2. The undersigned contracted with or was employed by ______________________. 3. A description of the labor, services, or materials furnished and the contract price or value thereof is as follows: labor/services/materials date cost/value ________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Notice of Furnishing of Labor or Materials Page 2 of 2 4. A description of the project is as follows: _______________________________________________________________________. 5. The undersigned is due the amount of $ _____________. 6. A copy of this notice has been provided to the project’s principal contractor and to the property owner of record by certified or registered mail. Post office receipts evidencing said mailings are attached hereto. This the _____ day of ______________, 20______. ________________________ Signature________________________ Type or Print Name State of South Dakota County of __________________ On this ______ day of __________________, 20______, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary Public, State of 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. So certified this the _____ day of _________________, 20______. ________________________ Signature