Fill and Sign the Notice of Non Responsibility Individual 490209938 Form

Notice of Non-Responsibility Page 1 of 2Prepared by, recording requested by and return to:Name: ____________________Company: _____________________Address: _____________________City: _________________State: _____Zip: __________Phone: ________________Fax: ________________ ----------------------Above this Line for Official Use Only---------------------Name of Claimant: ________________________________Name of Debtor: ________________________________Amount of Lien: _________________Tax Assessor’s Account Number: _________________Situs Address of Real Property: ________________________________________________________________________ NOTICE OF NON-RESPONSIBILITY – INDIVIDUAL (Or. Rev. Stat. §87.030) COMES NOW, ________________________________, as the owner of the property undergoing improvements located at and described as ______________________________________________________________________________________________________________________________________________ (legal description that includes a metes and bounds description; a lot, block, subdivision; the book and page and/or instrument number of a recorded deed where the legal can be found; or a parcel in a partition), and would state as follows:1.The undersigned property owner became aware that the above-described property was in the process of being improved on the _____ day of _____________, 20______.2.The undersigned hereby provides notice that said improvements are not being carried out at the instance of the undersigned owner and that the above-described property shall not be subject to a lien for any labor performed or materials provided. This the _____ day of ______________, 20______. _________________________ Signature _________________________ Type or Print Name _________________________ Notice of Non-Responsibility Page 2 of 2 _________________________Address