Fill and Sign the Notice of Mechanics Lien Mechanic or Laborer Working for 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 – Mechanic or Laborer Working for Contractor or Subcontractor – Corporation (Wa.V. Code. §38-2-13) To ________________________________ You will please take notice that the undersigned has performed work and labor under a contract with ________________________________ who was general contractor with you (or who was subcontractor with _____________________________, who was general contractor with you) in the erection and construction (or removal, repair, improvement or otherwise, as the case may be) of a certain building (or other structure or improvement) on real estate known as (here insert an adequate and ascertainable description of the real estate to be charged) and that the work and labor was of the kind, was performed on the dates, for the purposes and at the prices, as shown in the following itemized account thereof: (Here insert itemized account.) ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________________________________________________. You are further notified that the undersigned has not been paid the sum of $______________ (or that there is still due and owing to the undersigned thereon the sum of $ _______________) and that the undersigned claims a lien upon your interest in the said lot (or tract) of land and upon the buildings, structures and improvements thereon to secure the payment of the sum. ____________________________Signature____________________________Type or Print Name____________________________Title____________________________ Name of CorporationAttest: Secretary This instrument was prepared by _______________.State of West VirginiaCounty of ___________________________________________________, being first duly sworn, upon his or her oath says that the statements in the foregoing notice of mechanic's 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 VIRGINIACOUNTY OF ___________________This instrument was acknowledged before me on ________________ (date) by _________________________________ (name of officer or agent, title of officer or agent) of _________________________________ (name of corporation acknowledging) a ________________________ corporation (state or place of incorporation) on behalf of the corporation. ______________________________Notary PublicPrinted Name: _________________ My Commission Expires: _________________ Certificate of Delivery I, ___________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to the property owner ___________________________________ by: ( )Personal Delivery ( )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