HomeMy WebLinkAbout976310f STATE OF
COUNTY OF
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LIEN STATEMENT
Pursuant to the provisions of W.S. 29 -1 -312 relating to lien statements, the undersigned hereby
files this lien statement and swears as follows:
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1. Name and address of lien claimant: I Eg K, y tr 1 r -i- i-� 7 l G'
2. The amount claimed to be due and owing: 41, 1 I 00 plus pre judgment interest at a
rate of (if applicable), and attorneys' fees and costs incurred by lien claimant in the
collection of this amount.
3. The names and addresses of the persons against whose properties the lien is filed include:
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4. An itemized list setting forth and describing the work performed or materials furnished by the
lien claimant:
The amounts due and owing from for the work performed and /or materials provided are set forth
in the actual invoices, or if no invoices exist, then a summary, attached hereto as Exhibit "A
5. The name of the persons whom the lien claimant asserts is /are obligated to pay the debt
soured by the lien:
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6. The lien claimant last performed work, o furnished materials, for which the lien claimant
asserts a lien on the Cl day of C- 20 I
7. The legal description of the real property where the lien claimant performed work or furnished
materials is set forth in Exhibit "B attached hereto.
8. A true and accurate copy of the written contract, if available, under which the lien claimant
performed work or furnished materials is attached hereto as Exhibit "C If the contract was oral
or is too extensive, the parties to the contract and contract terms are described below:
976310 4/25/2014 3:48 PM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 831 PAGE: 183 LIEN STATEMENT
)EANNE WAGNER LINCOLN COUNTY CLERK
111111111111111111111111111111111111111111111111111111111111111111111111111
A copy of the written contract, if applicable, is located at the following address:
DATED this da y of 20
Name of lien claimant: DUO f lap I- F 1 w 't An
S ignature: L
Title: Pref.,'
Note to Notarial officer: If the lien claimant is a legal entity formed under Title 17 of the
Wyoming Statutes or other applicable law, use the first jurat. If the lien claimant is an individual
or sole proprietor, use the second jurat.
(Jurat 1:)
STATE OF
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OUNTY OF
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Witness my hand and official seal.
My Commission Expires: 3 (/(77
Seal:
M. RAMSPERGER
Notary Public
Lincoln County
Wyoming
My 'Commission Expires 7( 7
D H 14
•1q/ L:
On this 2 "day of 20 /subscribed and sworn to before me personally appeared
'Dot, ji* t rivA •to me personally known, who has read the foregoing Lien Statement and
knows the contents thereof and the facts are true to the best of his /her knowledge, and being by
me duly sworn, did state that he /she is ti: CSC 1, Enfi pitiVe 411C
t) of (lien claimant) and that this lien statement was signed and sealed on behalf of the
lien claimant by authority granted to the signatory by the lien claimant.