Fill and Sign the Notice to Disburser by Lien Claimant Individual Form

Notice to Disburser by Lien Claimant Page 1 of 2 NOTICE TO DISBURSER BY LIEN CLAIMANT-INDIVIDUAL (Colorado Revised Statute § 38-22-126(4)) Comes now, (Name) ________________________________, (Address)_______________________________________________________________, (Telephone Number)_______________________________, and hereby provides notice of the following:1.The undersigned lien claimant is entitled to a lien for labor performed, materials supplied or laborers furnished, for the purposes of improvements of property located at: ____________________________________________________________ and legally described as:____________________________________________________________ ___________________________________________________________.2. Said improvements were the result of a contract entered into between the undersigned and _________________________________ and the terms of the contract include: ____________________________________________________________ _______________________________________________________________________________________________________________________. This the _____ day of ______________, 20_____ . ________________________ Signature ________________________Print Name__________________________Title CO § 38-22-126(4) Notice to Disburser by Lien Claimant Page 2 of 2 Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( )Personal Service ( )Leaving a copy at the disburser’s residence or at his place of business with some person in charge located at ____________________________________________.( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to: ________________________________________________________________________(address).So certified this the ______ day of ___________________, 20____. ______________________________ Signature