Fill and Sign the Pennsylvania Lien 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: ________________ Claim of Lien -- Individual (Pa. Stat. Ann. tit 49, § 1503) COMES NOW, __________________________________ , as a contractor subcontractor who has provided labor and/or materials 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) and would state as follows : 1. The above-described property is owned by or reputed to be owned by _______________________________ , who may be reached at the following address _______________________________________________________________________ . 2. The undersigned ceased furnishing labor and/or materials on the       day of ____________ , 20       . 3. If the undersigned is a subcontractor, labor and/or materials were furnished under an agreement with contractor, ________________________________ . If required, a Preliminary Notice was provided on the       day of _______________ , 20       . A Formal Notice of Intention to Claim Lien was provided to the property owner on the       day of _________________ , 20       . 4. If the undersigned is a contractor, labor and/or materials were provided under a contract with the property owner executed on or about the       day of ________________ , 20       , and the following is a general statement of the kind and character of the labor and/or materials furnished: ________________________________________________________________________ 5. In cases other than where the undersigned is a contractor, the following is a detailed statement of the kind and character of the labor or materials furnished, or both, and the prices charged for each thereof: Claim of Lien Page 1 of 3 Labor/Materials Furnished Date Furnished Value/Cost _______________________________________________________________________ _ ______________________________________________________________________ __ _____________________________________________________________________ ___ _______________________________________________________________________ . 6. The amount due the undersigned for said labor and/or materials is $ _____________ . This the       day of _______________ , 20 _______ . _____________________________ Signature _____ _________________________ Type or Print Name Acknowledgment of Individual 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: _________________ Claim of Lien Page 2 of 3 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 Claim of Lien Page 3 of 3