Fill and Sign the Pennsylvania Assignment Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ____________________ Address: ______________________ City: ________________________ State: _____ Zip: _________ Phone: _____________________ Fax: _____________________ UPI Number: ________________ ASSIGNMENT OF LIEN- INDIVIDUAL Beginning on or about the _____ of _______________ , 20 _____ , the undersigned lienor, __________________________________ , furnished or supplied labor, materials, or laborers to ___________________________________ for the purpose of improvements to real property located at and described as _________________________________________________________________ (address should include municipality, ward (if in the city of Pittsburgh), county and state), such that the undersigned lienor is entitled to a lien for the value of labor, materials, or laborers supplied. Notice is hereby given that the above-mentioned lienor does hereby assign his or her claim and lien to ___________________________________ , who shall hereafter have all the rights and remedies under law to which the lienor is entitled subject to all defenses thereto that might be made if such assignment had not been made, for the purpose of filing and for the enforcement of the above-mentioned lien. This the _____ day of _______________ , 20 ______ . _________________________________ Signature of Lien Holder _____ _____________________________ Type or Print Name Assignment of Lien Page 1 of 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF _________________ On this, the ___ day of __________, 20____, before me a notary public, the undersigned officer, personally appeared________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In witness hereof, I hereunto set my hand and official seal. ___________________________ Notary Public ___________________________ Printed Name (Stamp or Seal) ________________ My Commission Expires: _____________________ Assignment of Lien Page 2 of 2