Fill and Sign the Statement of Correction Correcting the Assumed Entity Name Form

Notice of Non-Responsibility Page 1 of 2Prepared by, recording requested by and return to:Name: Company: Address: City: State: Zip: Phone: Fax: ----------------------Above this Line for Official Use Only--------------------- NOTICE OF NON-RESPONSIBILITY--Individual (Colorado Revised Statute §38-22-105(2)) Notice is hereby given that _____________________________________, owner having obtained notice of erection, construction, alteration, repair, or other improvement on the property located at ________________________________________ , hereby notices all parties engaged in performing labor, or providing materials or laborers, that any interest held by __________________________ in said property will not be subject to a lien for said erection, construction, alteration, removal, addition, repair, or other improvement. This the ____ day of ___________________, 20____. Signature of Owner Type or Print Name Notice of Non-Responsibility Page 2 of 2STATE OF COLORADOCOUNTY OF _____________________ The foregoing instrument was acknowledged before me this ____ day of ___________________, 20____ by ____________________________(name of person acknowledged). ______________________________Notary Public Printed Name: _________________ My Commission Expires: _____________________ Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to _________________________________ by:Personal ServiceSo certified this ____ day of ___________________, 20____. ______________________________ Signature CO § 38-22-105(2)