Fill and Sign the Notice of Nonresponsibility Individual Alaska Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: __________________ Address: _____________________ City: _____________________ State: ________ Zip: __________ Phone: ______________________ Fax: _______________________ NOTICE OF NONRESPONSIBILITY--INDIVIDUAL (A.S. § 34.35.065) COMES NOW, __________________________________ , as an owner or a person having or claiming an interest in the property undergoing improvement at ___________________________________ , and would state as follows: 1. On or about the _____ day of _______________ , 20 _______ , the undersigned owner or party in interest obtained knowledge of the construction, alteration, or repair taking place at the above-described property, and 2. Notice is hereby given that the undersigned will in no way be held responsible for the cost of said improvements or subject to a lien therefore. This the _____ day of __________ , 20 ______ . _________________________ Signature _______ ___________________ Print or Type Name Notice of Nonresponsibility Page 1 of 2 State of Alaska _________________ Judicial District (or County of _______________) The foregoing instrument was acknowledged before me this _____________________ day of ______________, 20___, by _____________________________ (signing party). ________________________________ Notary Public Print Name _______________________ Serial Number, if any: _______________ My commission expires: Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service with signed receipt ( ) Mailing a true and correct copy of same by first-class U.S. mail, postage prepaid, return signed receipt requested to ___________________________, So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Nonresponsibility Page 2 of 2