Fill and Sign the West Virginia Limited 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 Contractor or Subcontractor - Corporation (Wa.V. Code. §38-2-11) To __________________________________ You will please take notice that the undersigned ___________________________ has furnished and delivered to __________________________________ who was contractor with you (or subcontractor with _________________________________ , who was contractor with you, as the case may be) for use in the erection and construction (or repair, removal, improvement, as the case may be) of (here list the buildings or other structure or improvement to be charged) on the real estate known as (here insert an adequate and ascertainable description of the real estate to be charged) and the said materials were of the nature and were furnished on the dates and in the quantities and at the price as shown in the following 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 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 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