Fill and Sign the Wyoming Claim Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ____________________ Address: ______________________ City: ________________________ State: _____ Zip: _________ Phone: _____________________ Fax: _____________________ ASSIGNMENT OF LIEN- INDIVIDUAL Beginning on or about the _____ of _______________ , 20 _____ , the undersigned lienor, __________________________________ , furnished or supplied labor, materials, or laborers to ___________________________________ for the purpose of improvements of real property at _________________________________________________________________ , such that the undersigned lienor is entitled to a lien for the value of labor, materials, or laborers supplied. Notice is hereby given that the above-mentioned lienor does hereby assign his or her claim and lien to ___________________________________ , who shall hereafter have all the rights and remedies under law to which the lienor is entitled subject to all defenses thereto that might be made if such assignment had not been made, for the purpose of filing and for the enforcement of the above-mentioned lien. This the _____ day of _______________ , 20 ______ . __________________________________ Signature of Lien Holder _____ _____________________________ Type or Print Name Assignment of Lien Page 1 of 2 STATE OF WYOMING COUNTY OF __________________ This instrument was acknowledged before me on the ______ day of ______________ , 20 ______ , by __________________________________ (name(s) of person(s)). ___________________________________ (Seal, if any) (Signature of notarial officer) ___________________________________ Title (and Rank) My Commission Expires: __________________ Assignment of Lien Page 2 of 2