Fill and Sign the Washington Corporation 497429339 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: ____________________ Address: ______________________ City: __________________ State: _____ Zip: __________ Phone: _______________ Fax: _________________ CLAIM OF LIEN—CORPORATION Assessor’s Property Tax Parcel No./Account No. _______________________________ _______________________________ , Claimant vs _______________________________ , [Name of person indebted to claimant] Notice is hereby given that the person named below claims a lien pursuant to RCW 60.04. In support of this lien the following information is submitted: 1. NAME OF LIEN CLAIMANT: ____________________________ TELEPHONE NUMBER: ____________________________ ADDRESS: ____________________________ ____________________________ 2. DATE ON WHICH THE CLAIMANT BEGAN TO PERFORM LABOR, PROVIDE PROFESSIONAL SERVICES, SUPPLY MATERIAL OR EQUIPMENT OR THE DATE ON WHICH EMPLOYEE BENEFIT CONTRIBUTIONS BECAME DUE WAS THE _____ DAY OF __________________ , 20 ______ . 3. NAME OF PERSON INDEBTED TO THE CLAIMANT: _________________________________ . 4. DESCRIPTION OF THE PROPERTY AGAINST WHICH A LIEN IS CLAIMED (Street address, legal description or other information that will reasonably describe the property): ____________________________________________________________ ____________________________________________________________ ___________________________________________________________ . Claim of Lien Page 1 of 3 5. NAME OF THE OWNER OR REPUTED OWNER (If not known state Q "unknown"): _______________________________ . 6. THE LAST DATE ON WHICH LABOR WAS PERFORMED; PROFESSIONAL SERVICES WERE FURNISHED; CONTRIBUTIONS TO AN EMPLOYEE BENEFIT PLAN WERE DUE; OR MATERIAL, OR EQUIPMENT WAS FURNISHED WAS THE _____ DAY OF _______________ , 20 ______ . 7. PRINCIPAL AMOUNT FOR WHICH THE LIEN IS CLAIMED IS: __________________________________ . 8. IF THE CLAIMANT IS THE ASSIGNEEE OF THIS CLAIM, SO STATE HERE: _________________________________ . ______________________________ Corporation ______________________________ By _____ _________________________ Type or Print Name _____ _________________________ Title _____ _________________________ Street Address _____ _________________________ City, State, Zip Code _____ _________________________ Phone Number Attest: Secretary STATE OF WASHINGTON COUNTY OF __________________ , ss. _______________________________ , being sworn, says: I am the claimant (or attorney of the claimant, or administrator, representative, or agent of the trustees of an employee benefit plan) above named; I have read or heard the foregoing claim, read and Claim of Lien Page 2 of 3 know the contents thereof, and believe the same to be true and correct and that the claim of lien is not frivolous and is made with reasonable cause, and is not clearly excessive under penalty of perjury. Affiant ____________________________ Title ________ ________________________ Subscribed and sworn to before me this _____ day of _______________ , 20 ______ . ______________________________ Notary Public residing at _________ 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 the owner or reputed owner __________________________________ by: ( ) Personal Delivery ( ) 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 WA § 60.04.091 Claim of Lien Page 3 of 3