Fill and Sign the Physicians Lien Saampampi 4060 2000 State of Oklahoma Ss Form

Pre-Lien Notice – IndividualPage 1 of 3 Pre-Lien Notice-Individual (Okla. Stat. Ann. § 42-142.6) STATE OF OKLAHOMA ) ) ss. COUNTY OF ) TO: (Name) (Address) Re: Claimant: Improvement Location: COMES NOW, , as claimant or claimant’s representative whose address and telephone number is: (Name) (Address) and who is entitled or may be entitled to lien rights for the supply of materials, services, labor or equipment described as: supplied on (date) for improvements to the property located at: and/or legally described as: Pre-Lien Notice – IndividualPage 2 of 3 and provides to the original contractor, , and the owner of the property, , this Pre-Lien Notice and states the following: 1. The undersigned’s claim does not relate to the supply of material, services, labor, or equipment furnished in connection with a residential project, (a single family or multifamily project of four or fewer dwelling units none of which are occupied by the owner). 2. The dollar amount of the material, services, labor, or equipment furnished or to be furnished is Dollars ($ ). 3. This is a Pre-Lien Notice sent in compliance with Okla. Stat. Ann. § 42-142.6 prior to the filing of a lien statement and no later than seventy-five (75) days after the last date of supply of material, services, labor, or equipment in which the undersigned is entitled or may be entitled to lien rights. 4. This Pre-Lien Notice shall protect the undersigned’s lien rights for any subsequent supply of material, services, labor, or equipment furnished during the course of the construction project. 5. The name and last-known address of the person who requested that the undersigned provide the material, services, labor, or equipment is: (Name) (Address) Date: Signature of Claimant or Claimant’s Representative Type or Print Name STATE OF OKLAHOMA, COUNTY OF Subscribed and sworn before me, the undersigned, a Notary Public, in and for said County and State, this the day of , 20 . ___________________________ Notary Public Pre-Lien Notice – IndividualPage 3 of 3 Print Name: _________________ My commission expires: _____________________ CERTIFICATE OF SERVICE I, (name), certify that I am , and at all times during the service of process was, not less than 18 years of age and not a party to the matter concerning which service was made. I further certify that the service was made (date) by: Certified Mail, return receipt requested: Hand Delivery by the United States Postal Service supported by a delivery confirmation receipt; or By automated transaction pursuant to Section 15-115 of Title 12A of the Oklahoma Statutes. Under penalty of perjury, I declare the foregoing is true and correct. Date: Signature Print Name: Business Address: City: State: Zip: