Fill and Sign the South Dakota Lien 497326152 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: ____________________ Address: ______________________ City: ___________________ State: ______ Zip: __________ Phone: ________________ Fax: ________________ Lien Statement – Corporation (S.D. Codified Laws Ann. §44-9-15 and §44-9-16) COMES NOW, _________________________________ , as a representative of __________________________________ a ____________________________________ corporation which has provided labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , and would state as follows: 1. Notice is hereby given that the undersigned intends to claim and hold a lien against the above described property in the amount of $ _______________ . 2. The above amount is due and owing to the claimant for labor performed, or for skill, services, material, or machinery furnished to ____________________________________ at the following address: _______________________________________________________________________ . Said labor and/or materials were furnished for the following improvement: _____________________________________________________________________ . 3. The undersigned lien claimant may be reached at the following mailing address: _____________________________________________________________________ . 4. The first and last items furnished by the claimant were furnished on the _____ day of ______________ , 20 ________ , and the _____ day of _____________ , 20 _______ , respectively. 5. According to the best information available to the lien claimant, the name and address of the owner of the above described property is _______________________________________________________________________ . Lien Statement Page 1 of 3 6. An itemized account of the lien claim is as follows: Labor/Materials Date provided Value/Cost ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 7. The full amount of said lien claim is $ ______________ . 8. Pursuant to South Dakota statutes, a copy of this lien notice has been provided to the property owner at his or her last known address by registered or certified mail. A copy of the post-office receipt for said mailing is attached. This the _____ day of _____________ , 20 _______ . _________________________ Signature _____ ____________________ Type or Print Name _____ ____________________ Title _____ ____________________ Corporation Attest: Secretary State of South Dakota County of __________________ On this , the ______ day of ____________ , 20 ______ , before me, ______________________________ , the undersigned officer, personally appeared ______________________________ , who acknowledged himself to be the ____________ of ________________________ , a corporation, and that he/she, as such ________________________ being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself/herself as __________________ . In witness whereof I hereunto set my hand and official seal. Notary Public, State of ____________ Lien Statement Page 2 of 3 My commission expires:       Type or Print Name Certificate of Delivery I, __________________________________ , hereby certify that I have delivered this day a true and correct copy of the foregoing to the property owner by: ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested to _________________________________ . So certified this the _____ day of _______________ , 20 ______ . ________________________ Signature Lien Statement Page 3 of 3