Fill and Sign the Notice of Intent to Lien to Owner and Prime Contractor Form

Notice of Intent to Lien to Owner and Prime Contractor Page 1 of 3Prepared by, recording requested by and return to:Name: __________________Company: ________________Address: __________________City: ________________State: _____Zip:__________Phone:_______________Fax:______________----------------------Above this Line for Official Use Only---------------------NOTICE OF INTENT TO LIEN TO OWNER AND PRIME CONTRACTOR— INDIVIDUAL (Nevada Revised Statute §108.226(6) (Assessor's Parcel Numbers: ____________________________________ )The undersigned hereby claims an intent to lien upon the property described in this notice for work, materials or equipment furnished or to be furnished for the improvement of the property involving the construction, alteration or repair of a multifamily or single-family residence, including without limitation an apartment house and would state the following:1. The amount of the original contract is: $______________________.2. The total amount of all additional or changed work, materials and equipment, if any, is: $______________________.3. The total amount of all payments received to date is $______________________. 4. The amount of the lien, after deducting all just credits and offsets, is $______________________.5. The name of the owner, if known, of the property is ___________________________.6. The name of the person by whom the lien claimant was employed or to whom the lien claimant furnished or agreed to furnish work, materials, or equipment is: __________________________________.7. A brief statement of the terms of payment of the lien claimant’s contract is: ________________________________________________________________________ _______________________________________________________________________. Notice of Intent to Lien to Owner and Prime Contractor Page 2 of 38. A description of the property to be charged with the lien is: ________________________________________________________________________ _______________________________________________________________________. (If provided in metes and bounds, also include the name and mailing address of the person who prepared the legal description. If a document including the same legal description previously has been recorded, include all information necessary to identify and locate the previous recording, but not the name and mailing address of the person who prepared the legal description). According to NRS 108.226(6), this notice of intent to lien has been served on the owner and the reputed prime contractor prior to the recording of the notice of lien and will extend the time for recording the notice of lien by fifteen (15) days. DATED this _____ day of ______________, 20______. _____________________________ Signature of Lien Claimant______________________________Type or Print NameState of Nevada ) ) ss.County of ___________)____________________________________ (print name), being first duly sworn on oath according to law, deposes and says:I have read the foregoing Notice of Intent to Lien, know the contents thereof and state that the same is true of my own personal knowledge, except those matters stated upon information and belief, and, as to those matters, I believe them to be true. ___________________________________________ (Authorized Signature of Lien Claimant)Subscribed and sworn to before me this _____ day of the month of _____________ of the year _________._____________________________________ Notary Public in and for the County and State Notice of Intent to Lien to Owner and Prime Contractor Page 3 of 3 CERTIFICATE OF DELIVERY I, , hereby certify that I have delivered this day a true and correct copy of the foregoing to by: (select one of the options) Personal Service; or By mailing a copy of the above document by certified mail, return receipt requested, on the above individual at the following address: So certified this the ______ day of ___________________, 20____.Signature Print/Type Name