Fill and Sign the Wyoming Statement Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ___________________ Company: ____________________ Address: ____________________ City: __________________ State: _____ Zip: __________ Phone: _________________ Fax: ________________ LIEN STATEMENT –INDIVIDUAL (Wyo. Stat. §29-1-301, 29-2-106) COMES NOW, _________________________________ , of ___________________________________________________________________ (address) as a party who has performed work or furnished materials for the improvement of the property located at and described as ________________________________________________________________________ ______________________________________________________________________ , and would state as follows: 1. The undersigned began providing labor and/or materials under a contract, a copy of which is attached, if available, for the above-described property on the _____ day of ________________ , 20 ______ . 2. Work was substantially completed or the contract to furnish materials was substantially completed on or about the _____ day of ______________ , 20 ______ . 3. The undersigned has furnished the following labor and/or materials: Labor/Materials Date Cost/Value ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 4. The undersigned hereby claims a lien against _________________________________ and the above described property owned by _________________________________ of ___________________________________________________________________ (address) in the amount of $ ______________ . Lien Statement Page 1 of 2 This the _____ day of ______________ , 20 ______ . ______________________________ Signature _____ _________________________ Type or Print Name STATE OF WYOMING COUNTY OF __________________ Signed and sworn to (or affirmed) before me on the ______ day of ______________ , 20 ______ , by __________________________________ (name(s) of person(s) making statement). ___________________________________ (Seal, if any) (Signature of notarial officer) ___________________________________ Title (and Rank) 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 last known owner, by: ( ) Mailing a true and correct copy of same by certified U.S. mail, postage prepaid, return receipt requested to __________________________________ . So certified this the _____ day of ______________ , 20 ______ . ________________________ Signature WY § 29-2-106 Lien Statement Page 2 of 2