Fill and Sign the West Virginia Lien 497431612 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 – Mechanic or Laborer Working for Contractor or Subcontractor – Corporation (Wa.V. Code. §38-2-13) To ________________________________ You will please take notice that the undersigned has performed work and labor under a contract with ________________________________ who was general contractor with you (or who was subcontractor with _____________________________ , who was general contractor with you) in the erection and construction (or removal, repair, improvement or otherwise, as the case may be) of a certain building (or other structure or improvement) on real estate known as (here insert an adequate and ascertainable description of the real estate to be charged) and that the work and labor was of the kind, was performed on the dates, for the purposes and at the prices, as shown in the following itemized account thereof: (Here insert itemized account.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________ . You are further notified that the undersigned has not been paid the sum of $ ______________ (or that there is still due and owing to the undersigned thereon the sum of $ _______________ ) and that the undersigned claims 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 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 the property owner ___________________________________ 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