Fill and Sign the Notice of Mechanics Lien Contractor Individual Form

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 Mechanic's Lien – Contractor- Individual(W. Va. Code §38-2-8) To: __________________________________ Notice is hereby given, in accordance with the laws of the State of West Virginia, that the undersigned claims a lien to secure the payment of the sum of $ ________________ upon your interest in and to lot number _____________ of block number ______________ as shown on the official map of the city of ___________________________________ (or other adequate and ascertainable description of the real estate to be charged), and upon the following buildings, structures and improvements thereon: (List the buildings, structures or improvements sought to be charged.) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Given under my hand this _____ day of _____________, 20______. ____________________________ Signature____________________________ Type or Print Name This instrument was prepared by _______________. State of West Virginia, County of _______________ ___________________________________, being first duly sworn, upon his oath says that the statements contained in the foregoing notice of lien are true, as he or she verily believes. Taken, subscribed and sworn to before me this _____ day of _______________, 20______. My commission expires: _______________. ____________________ (Official Capacity) STATE OF WEST VIRGINIA COUNTY OF ________________ This instrument was acknowledged before me on ________________ (date) by _________________________________ (name or names of person or persons acknowledging). _________________________ Notary Public Printed Name: ____________________ My Commission Expires: _______________