Fill and Sign the Single Family Dwelling Form

NOTICE TO OWNER- Owner-occupied single or double family dwelling -Corporation (K.R.S.A. § 376.010(4)) COMES NOW, _____________________________________ , as a representative of ________________________________ a _________________________________ corporation, which may be served at the following address _______________________________________________________________________ , and would state as follows: 1. The undersigned corporation ( ) has furnished ( ) will furnish labor or materials for the improvement of the owner-occupied single or double family dwelling located at _________________________________________________________________ . 2. The above-mentioned property is owned and occupied by _________________________________ . 3. The value of the labor and/or materials in full, with all credits and setoffs known to the undersigned, is $ ____________ . 4. The above-mentioned labor and/or materials were not furnished by the undersigned under a direct contract with the property owner or his agent. 5. Labor and/or materials were last provided on the _____ day of _____________ , 20 ______ , said date being within seventy-five (75) days of the date of this notice. 6. The undersigned is entitled to a lien and intends to hold the above-described property liable for the above lien amount. ______________________________ Signature _____ _________________________ Type or Print Name _____ _________________________ Title _____ _________________________ Corporation Notice to Owner Page 1 of 2 Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________the property owner at his/her last known address, or to his/her duly authorized agent, a party other than the contractor or subcontractor, by: ( ) Regular Mail ( ) Registered Mail ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to ____________________________. So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice to Owner Page 2 of 2