Fill and Sign the West Virginia Corporation 497431634 Form

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 Mechanic's Lien – Supplier to Owner- Corporation (Wa.V. Code. §38-2-10) To _________________________________ Notice is hereby given, in accordance with the laws of the State of West Virginia, that the undersigned claims a lien to secure the payment of the sum of $ __________________ upon your interest in and to lot number __________ block number __________ as shown on the official map of the city of _____________________________ (or other adequate and ascertainable description of the real estate to be charged) and upon the following buildings, structures and improvements thereon ________________________________________________________________________ _______________________________________________________________________ , (list the buildings, structures or improvements sought to be charged). Given under my hand this _____ day of ______________ , 20 _____ . ____________________________ Signature _____ _______________________ Type or Print Name _____ _______________________ Title _____ _______________________ Name of Corporation Attest: Secretary This instrument was prepared by _______________ . State of West Virginia County of _________________ _________________________________ , being first duly sworn, upon his or her oath says that the statements in the foregoing notice of lien are true, as he or she verily believes. Taken, subscribed and sworn to before me this _____ day of ______________ , 20 ______ . My commission expires _________________ ________________________ (Official Capacity) STATE OF WEST VIRGINIA COUNTY OF _______________ This instrument was acknowledged before me on ________________ (date) by _________________________________ (name of officer or agent, title of officer or agent) of _________________________________ (name of corporation acknowledging) a ________________________ corporation (state or place of incorporation) on behalf of the corporation. ______________________________ 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 Delivery ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested. So certified this the _____ day of ________________ , 20 ______ . ________________________ Signature