Fill and Sign the West Virginia 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 – Contractor- Corporation (W. Va. Code §38-2-8) 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 _____________ of 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 contained 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: _______________