Fill and Sign the Rhode Island Notice Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ____________________ Address: _____________________ City: ____________________ State: _____ Zip: __________ Phone: _________________ Fax: _________________ NOTICE OF INTENTION TO CLAIM LIEN - INDIVIDUAL (R.I. Gen. Laws § 34-28-4) To: _________________________________ (Name of owner of record/Lessee) __________________________________________ __________________________________________ (Address of owner/Lessee) NOTICE OF INTENTION TO DO WORK OR FURNISH MATERIALS, OR BOTH All persons are hereby notified that the undersigned has within the two hundred (200) days prior to the mailing hereof done work, furnished materials, or both, and/or intends to do so in the future (cross out inappropriate words), in the construction, erection, alteration, or preparation of an improvement on land described as follows: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ , and that the land is owned by or leased to (here insert name of owner or lessee or tenant) ________________________________ . The nature of the work being done or materials being furnished is as follows: (here insert general description of the nature of the work or materials, or both) ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ , and is being done for or furnished to (here insert name of person or persons for whom directly the work is being done or to whom directly the materials are being furnished), _________________________________ whose address is (here insert address) _______________________________________________________________________ . Notice of Intention to Claim Lien Page 1 of 3 The approximate value of said work or materials is, as of the date of the notice, $ _______________ , itemized as follows: ________________________________________________________________________ ___________________________________________________________________ , and the undersigned has not been paid for the work or materials or both; The undersigned authorizes (here insert name or names) __________________________________ , to act or sign documents in behalf of the undersigned in all matters pertaining to this notice, or any lien claimed hereunder, or release thereof. You are hereby informed that the undersigned may within two hundred (200) days of the performance of the work or furnishing of the materials, file in the records of land evidence of the city or town of _____________________________ a copy of this notice of intention to do work or furnish materials. The filing of the notice of intention, together with this mailing, will perfect a lien against the land described herein, under and subject to the provisions of the Rhode Island Mechanics' Lien Law. ____________________________________ Signature ______ ______________________________ Type or Print Name ______ ______________________________ ____________________________________ Address NOTARIZATION CLAUSE ___________________________ Signed and sworn before me this the _______ day of __________________ , 20 ______ . ______________________________ Notary Public My Commission Expires: __________________ Notice of Intention to Claim 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 mailing a true and correct copy of same by registered or certified U.S. mail, postage prepaid, return receipt requested to __________________________________ . So certified this the _____ day of _____________ , 20 ______ . ________________________ Signature Notice of Intention to Claim Lien Page 3 of 3