Fill and Sign the Notice of Furnishing Professional Individual Kentucky 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 Professional Engineers, Land Surveyors, Licensed Architects and Landscape Architects. (K.R.S.A. § 376.075) COMES NOW, _____________________________________ , of the following address ______________________________________________________________________ , and would state as follows: 1. The undersigned is a professional engineer, land surveyor, licensed architect, or landscape architect who performed professional services for the improvement of the property located at ______________________________________________________________________ and described as _______________________________________________________________________ . 2. The above-mentioned property is owned by _______________________________ . 3. The value of the services performed, with all credits and setoffs known to the undersigned, is $ _____________ . 4. The above-mentioned services were provided by the undersigned under contract directly with the ( ) property owner, or his agent, ( ) a contractor, ( ) an architect. 5. The undersigned ceased providing services on the _____ day of _____________ , 20 ______ , said date being within six (6) months of the date of the filing of this Notice. 6. Pursuant to Kentucky Revised Statute Annotated § 376.075, the undersigned is entitled to a lien for the above amount. ______________________________ Signature Notice of Furnishing Page 1 of 2 _____ _________________________ 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 ___________________________________ 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