Fill and Sign the Petition for the Issuance of Automobile Title Fulton County Indiana Form

Notice of Lien – Corporation Page 1 of 3 Notice of Lien - Corporation (I.C.A. § 32 -28-3-3(a)) State of Indiana County of ____________________ COMES NOW ____________________________________ , as representative of ________________________________ a/an _________________________________ corporation of (address) ________________________________________________ , and hereby provides notice of the following: 1. The undersigned has performed labor or furnished material or machinery for improvements to the pr operty located at (legal description and street address, if any) Street Address: Legal Descrip tion: 2. The above -mentioned property is owned by ________________________ of (address) ____________________________________________________________ . 3. The undersigned corporation is entitled to a lien for the value of labor performed or material furnished in the amount of $ ____________ . Notice of Lien – Corporation Page 2 of 3 4. The undersigned performed labor or furnished material on the _____ day of _____________ , 20 ______ , being within ninety (9 0) days of the filing of this notice. Signature Type or Print Name Title Corporation Attest: Secretary STATE OF INDIANA , County, ss: Before me, the undersigned, a Notary Public in and for said County and State, personally appeared the withi n named , who acknowledged the execution of the foregoing NOTICE OF LIEN for and on behalf of said ________________________ , a corporation , and who, being duly sworn, stated that the representations therein contained are true. Witness my hand and Seal this day of , 20 . Notary Public. Resident of County. My Commission expires , 20 Notice of Lien – Corporation Page 3 of 3 This Instrument was prepared by: Signature Print or Type Name Affirmation Statement I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document, unless req uired by law. Signature Print or Type Name