Fill and Sign the Vermont Lien Form 497428658

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: __________________ Company: ____________________ Address: ____________________ City: ____________________ State: _____ Zip: __________ Phone: _________________ Fax: _________________ Notice of Claim of Lien – Corporation (Vt. Stat. Ann. tit. 9 § 1921) COMES NOW, _________________________________ , as a representative of __________________________________ a _________________________________ corporation which has performed labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ _________________________________________________ , and would provide notice of the following: 1. The undersigned began to furnish labor and/or materials for the improvement of the above-described property on or about the _____ day of _________________ , 20 _______ . 2. The undersigned provided the following labor and/or materials for the improvement of the above described property: labor/materials date cost/value _____________________________________________________________ __________ ___________________________________________________ ____________________ _________________________________________ ______________________________ _______________________________ ________________________________________ _____________________ __________________________________________________ ___________ ____________________________________________________________ _ _____________________________________________________________ _________ ____________________________________________________ ___________________ __________________________________________ . Notice of Claim of Lien Page 1 of 2 3. The undersigned hereby provides notice to the owner of the above described property that the undersigned claims a lien against said property for labor provided or materials furnished in the amount of $ _______________ . This the _____ day of ________________ , 20 ______ . ____________________ Signature _____ _______________ Type or Print Name _____ _______________ Title _____ _______________ Corporation Attest: Secretary State of Vermont County of ___________________ I, _________________________________ , a notary public in and for the state and county aforesaid, do certify that _______________________________ (or _____________________________ and _______________________________ ), whose name (or names), as _______________________________ (or _______________________________ and ________________________________ ) of ___________________________________ (insert name of corporation), is (or are) signed to the writing above, bearing date on the _____ day of ___________________ , ________ , has (or have) acknowledged the same before me in the county aforesaid. Given under my hand and seal this _____ day of ___________________ , ________ . ___________________________________ Notary Public, State of Printed Name: _______________________ My Commission Expires: ___________________ Notice of Claim of Lien Page 2 of 2