Fill and Sign the Verified Notice of Intention to Claim Mechanics Lien Individual 497317443 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: __________________ Company: __________________ Address: ____________________ City: _________________ State: _____ Zip: __________ Phone: _______________ Fax: ________________ VERIFIED NOTICE OF INTENTION TO CLAIM MECHANIC’S LIEN - INDIVIDUAL (N.D.S. § 35-27-05) COMES NOW, ________________________________ , as a person who has a contract for the improvement of land in accordance with N.D.S. § 35-27-02, and hereby provides notice of the following: 1. ________________________________ is in possession of the real property located at and described as ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 2. The undersigned contracted with ________________________________ on __________________ (date) to provide the following improvements to the above- described real property ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 3. The undersigned completed the above-described improvements on ___________________ (date). There remains due, owing and unpaid on the contract the sum of _______________ as of ________________ (date), and a _____ % late payment charge each month thereafter, if applicable. 4. The undersigned will perfect a mechanic’s lien against the building, improvement or premises according to law unless the account is paid within fifteen (15) days of the date of this Notice. Dated _______________________ Verified Notice of Intention to Claim Mechanic’s Lien Page 1 of 2 ________________________ Signature _____ ____________________ Type or Print Name I, _________________________________ , do hereby swear or affirm that the matters alleged and things contained in the above Verified Notice of Intention to Claim Mechanic’s Lien are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF NORTH DAKOTA COUNTY OF _________________ The foregoing instrument was acknowledged before me this _____ day of _______________ , 20 ______ by __________________________________ (name of person acknowledging). _____________________________ Notary Public Printed Name: _________________ My Commission Expires: _________________ Verified Notice of Intention to Claim Mechanic’s Lien Page 2 of 2