Fill and Sign the Notice Termination Form 497309610

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 TERMINATION--INDIVIDUAL (Mass. Gen. Laws Ann. ch. 254 § 2B) Notice is hereby given that a written contract dated the _____ day of __________________ , 20 ______ , between __________________________________ as Owner and ________________________________ as Contractor for the erection, alteration, repair or removal of a building, structure or other improvement of real property described below, has been terminated. The lot of land or other interest in real property which is the subject of such contract is described as follows: ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________ . Legal Description of Property] The undersigned Owner hereby states that he or she has served written notice of the recording or filing of this Notice of Termination upon the contractor and every person who has filed or recorded prior to this date a Notice of Contract under section four of chapter two hundred and fifty-four of the General Laws. This the _____ day of ______________ , 20 _________ . ________________________ Signature _____ ___________________ Type or Print Name State of Massachusetts County _____________ On this _______ day of _________, 20 ___, before me the undersigned notary public, personally appeared ________________________________________ (name of document signer), proved to me through satisfactory evidence of identification, which were _________________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he or she signed it voluntarily for its stated purpose. _____________________ Notary Public Print Name: ___________________ My commission expires: ____________________ Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing Notice of Termination, as filed and recorded, to ___________________________________ by mailing a true and correct copy of same by certified mail, return receipt requested , U.S. mail, postage prepaid to ___________________________, at his/her usual place of business located at ______________________________________. So certified this the ______ day of ___________________, 20____. _____________________________ Signature MA Ch. 254, § 2B