Fill and Sign the Statement of Claim Individual Delaware Form

STATEMENT OF CLAIM— INDIVIDUAL (25 Del. C. §2712) COMES NOW, the undersigned Plaintiff/Claimant, having provided materials or labor for the improvement of the below-described structure, and files this Statement of Claim, and in support thereof would state as follows: 1. The name of the plaintiff/claimant who provided materials or labor is ___________________________________ . 2. The owner or reputed owner of the structure improved is __________________________________ . 3. The contractor on the project is ___________________________________ . 4. The undersigned provided labor or materials under a contract with: ( ) the property owner, ( ) the owner’s agent, or ( ) the contractor. 5. Labor and/or materials began being furnished on ____________________________________ . Statement of Claim Page 1 of 3Tax Parcel Identification Number (if applicable) _____________________ Prepared by, recording requested by and return to: Name: ___________________ Company: _____________________ Address: _____________________ City: _______________________ State: _____ Zip: __________ Phone: _______________________ Fax: __________________________ 6. Labor and/or materials ceased being furnished on ___________________________________ . 7. The structure being improved is located at: ___________________________________ . 8. The labor and/or materials provided were furnished on the credit of the above-mentioned structure. 9. The plaintiff/claimant has a claim for the amount of ________________________________________________ ($ ___________________ ), such amount being in excess of twenty-five dollars ($25.00) , and that neither this amount nor any part thereof has been paid to plaintiff; and 10. The amount that is due to plaintiff/claimant on each structure is __________________________________________________ ($ _________________ ). 11. A first mortgage, or a conveyance in the nature of a first mortgage was recorded on ___________________________________ , and was granted to secure an existing indebtedness or future advance provided at least 50% of the loan proceeds are used for the payment of labor or materials, or both. This the _____ day of ____________________ , 20 _____ . ________________________ Signature _____ ___________________ Print or Type Name STATE OF DELAWARE COUNTY OF ________________ Before me, _____________________________, a Notary Public in and for the County of _______________, State of Delaware, personally appeared __________________________, who being duly Statement of Claim Page 2 of 3 sworn, doth depose and say: That he has personal knowledge of the facts set forth in the foregoing Statement of Claim, and that the same are true and correct to the best of his knowledge and belief. ____________________________ Affiant ____________________________ [DATE} Signed and sworn to (or affirmed) before me on ________________________ by ______________________________________ [Person(s) making statement]. ________________________ Signature of Notarial Officer ________________________ Print Name: ________________________ Title and Rank: ____________________ SEAL (if any) My commission expires: ____________________ DE Tit. 25, § 2712(b) Statement of Claim Page 3 of 3