Fill and Sign the Statement of Account Individual South Carolina 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 – Individual (S.C. Code Ann. §29-5-90) State of South Carolina County of _______________ COMES NOW, ________________________________ , as a party who 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 2 This the _____ day of _____________ , 20 _______ . _____________________________ Signature _____ _________________________ Type or Print Signature Witnessed or Attested by: ____________________________ ____________________________ Subscribed and sworn to before me on this the ___________ day of _______________, 20______, by said affiant. ______________________________ Notary Public My Commission Expires: __________________________________ Acknowledgment of Individual STATE OF SOUTH CAROLINA COUNTY OF ____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged). ____________________________________ Notary Public Print Name: _________________________ My commission expires: ____________________ Statement of Account Page 2 of 2