Fill and Sign the Notice of Mechanics Lien Mechanic or Laborer Working for Owner 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 – Mechanic or Laborer Working for Owner - Individual (Wa.V. Code. §38-2-12) 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 VirginiaCounty of ___________________________________________________, being first duly sworn, upon his or her 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: _________________