Fill and Sign the Use Only Lien Statement Individual Form

Lien Statement Page 1 of 3 Prepared by, recording requested by and return to: Name: _____________________ Company: ___________________ Address: ______________________ City: _________________ State: ______ Zip: __________ Phone: __________________ Fax: __________________ ----------------------Above this Line for Official Use Only--------------------- Lien Statement – Individual (S.D. Codified Laws Ann. §44-9-15 and §44-9-16) COMES NOW, ___________________________________, as a party who 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 2 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 State of South Dakota County of __________________ On this ______ day of __________________, 20______, before me, ______________________________, the undersigned officer, personally appeared ______________________________, known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary Public, State of My commission expires: Type or Print Name Lien Statement Page 3 of 3 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