Fill and Sign the Pennsylvania Claim 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: ________________ Demand for Filing of Claim by Entry of Rule -- Corporation (Pa. Stat. Ann. tit 49, § 1506(a)) COMES NOW, _________________________________ , as representative of _______________________________________ a _______________________________ corporation acting as a contractor responsible for the alteration, repair, erection, or construction of the property located at and described as _______________________________________________________________________ (address should include municipality, ward (if in the city of Pittsburgh), county and state), or as the owner of said property, and would state as follows : 1. On or about the       day of ____________ , 20       , labor and/or materials began to be provided for the alteration, repair, erection, or construction of the above described property by subcontractor, __________________________________ . 2. The above named subcontractor completed work on the       day of _____________ , 20       . 3. Pursuant to Pennsylvania Statute Annotated Title 49, Section 1506(a), the undersigned hereby files this rule and demands that the above named subcontractor file a lien claim for the value of labor and/or materials provided by the subcontractor within thirty (30) days of receipt of this notice, or be forever barred from so doing. This the       day of ______________ , 20       . _________________________ Signature _____ ____________________ Type or Print Name       ___________________ Title       Corporation Demand for Filing of Claim by Entry of Rule Page 1 of 2 Attest: Secretary Acknowledgment of Corporation COMMONWEALTH OF PENNSYLVANIA COUNTY OF __________________ On this, the _____ day of _____________ , 20 ______ , before me a notary public, the undersigned officer, personally appeared __________________________________ , as the __________________ (type of authority, e.g., officer, trustee, etc.) of _________________________________ (name of party on behalf of whom instrument was executed) 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: _______________ Certificate of Delivery I, ___________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to __________________________________ by: Personal Service Mailing a true and correct copy of same by first class registered or certified U.S. mail, postage prepaid, return receipt requested to __________________________________ . So certified this the _____ day of _______________ , 20 _____ . ________________________ Signature Demand for Filing of Claim by Entry of Rule Page 2 of 2