Fill and Sign the South Carolina Corporation Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ___________________ Address: __________________ City: __________________ State: _____ Zip: __________ Phone: ______________ Fax: _______________ Statement of Account – Corporation (S.C. Code Ann. §29-5-90) State of South Carolina County of _______________ COMES NOW, ___________________________________ , as a representative of ________________________________ a _________________________________ corporation which has supplied labor, material, or services for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , and would provide notice of the following: 1. The above-described property is owned by ____________________________ . 2. The following labor, services, or materials have been furnished by the undersigned: labor/services/materials cost/value ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 3. The undersigned is due the sum of $ ____________ for said furnishing, after all just credits are given, and is entitled to a lien against the above described property for said amount. 4. The last date the undersigned performed work or furnished materials was the _____ day of ________________ , 20 _______ . Statement of Account Page 1 of 3 This the _____ day of _____________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name _____ _________________________ Title _____ _________________________ Corporation Attest: Secretary Witnessed by: ____________________________ ____________________________ Subscribed and sworn to before me on this the ___________ day of _______________, 20______, by said affiant. ______________________________ Notary Public My Commission Expires: __________________________________ Acknowledgment of Corporation State of South Carolina County of ____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of officer or agent, title of officer or agent) of ____________________________ (name of corporation acknowledging) a ___________________________________ (state or place of incorporation) corporation, on behalf of the corporation. Statement of Account Page 2 of 3 ____________________________________ Notary Public Print Name: _________________________ My commission expires: ___________________ Statement of Account Page 3 of 3