Fill and Sign the Owners Supplying Their Own Materials Markup and Profit Form

Response to Demand of Supplier of Materials Page 1 of 2 RESPONSE TO DEMAND OF SUPPLIER OF MATERIALS, MACHINERY, TOOLS, LABORERS, OR SERVICES FOR INFORMATION REGARDING OWNER, DISBURSER AND PRINCIPAL CONTRACTOR - CORPORATION (Colorado Revised Statute §38-22-126(3)) COMES NOW, _________________________________, the undersigned who has ordered or contracted for labor, services, machinery, tools, equipment, laborers, or materials from __________________________________ to be used in the improvement of property and responds to the Demand of Supplier of Materials, Machinery, Tools, Laborers, or Services for Information Regarding Owner, Disburser, and Principal Contractor that he or she received on _____ day of ______________ , 20_____ as follows: 1.The name, address, and telephone number of the owner or reputed owner of the land to be improved is: _______________________________________________________________________________________________________________________________________________.2. The name, address and telephone number of the principal contractor, if any is:________________________________________________________________________ _______________________________________________________________________.3.The name, address and telephone number of the disburser, if any is: ________________________________________________________________________ _______________________________________________________________________. 4. A legal description or the address, if any, of the land to be improved is:______________________________________________________________________ ________________________________________________________________________________________________________________________________________________ _________________________________________. This the _____ day of ________________ , 20_____. ___________________________________ Corporation Name____________________________________SignaturePrint Name: _________________________ Title: ______________________________ Response to Demand of Supplier of Materials Page 2 of 2STATE OF COLORADO COUNTY OF ____________________ In _______________, on the _____ day of ____________, 20___, before me, a Notary Public in and for the above state and county, personally appeared _____________________________________________, known to me or proved to be the person named in and who executed the foregoing instrument, and being first duly sworn, such person acknowledged that he or she executed said instrument for the purposes therein contained as his or her free and voluntary act and deed. Type of ID Produced: _________________________Affiant __ is __ is not personally known to me _______________________________ NOTARY PUBLIC My Commission Expires: _____________________ (SEAL) CO § 38-22-126(3)