Fill and Sign the West Virginia Lien 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 – Subcontractor- Corporation (Wa.V. Code. §38-2-9) To _________________________________ You will please take notice that the undersigned _____________________________ was and is subcontractor with ________________________________ who was and is general contractor for the furnishing of materials and doing of the work and labor, necessary to the completion of (here describe the nature of the subcontract) ________________________________________________________________________ _______________________________________________________________________ , on that certain building (or other structure or improvement as the case may be), owned by you and situate on lot number __________ of block number ____________ as shown on the official map of __________________________________ (or other definite and ascertainable description of the real estate) and that the contract price and value of said work and materials is $ ______________ . You are further notified that the undersigned has not been paid therefore (or has been paid only $ _____________ thereof) and that the undersigned claims and will claim a lien upon your interest in the said lot (or tract) of land and upon the buildings, structures and improvements thereon to secure the payment of the said sum. ____________________________ 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 mechanic's 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