Chapter 19 - EXHIBIT 19A • STATEMENT OF MECHANICS' LIEN WITH NOTICE OF INTENT TO FILE A LIEN STATEMENT AND AFFIDAVITS OF SERVICE

• Jurisdiction: Colorado

EXHIBIT 19A • STATEMENT OF MECHANICS' LIEN WITH NOTICE OF INTENT TO FILE A LIEN STATEMENT AND AFFIDAVITS OF SERVICE STATEMENT OF MECHANICS' LIEN Sections 38-22-101 through 38-22-133, Colorado Revised Statutes

In accordance with Sections 38-22-101 through 38-22-133, Colorado Revised Statutes, __________ ("Lien Claimant") makes the following Statement of Lien:

1. The name of the owner or reputed owner of the property to be affected by the lien is __________.

2. The name and mailing address of the Lien Claimant are __________, □ a subcontractor, □ a principal contractor.

3. The name of the person who furnished the laborers or materials or performed the labor or services, or supplied the machinery, tools or equipment for which said lien is claimed is __________.

4. The name of the principal contractor is __________.

5. The property to be affected by such lien is described as follows:

also known by street number as __________ situate in the __________ * County of __________, State of Colorado.

6. The Mechanics' Lien is held for and on account of __________.

7. The amount of indebtedness due or owing the Lien Claimant for which said lien is claimed, for laborers or material furnished, labor and services performed, machinery, tools and equipment supplied is $__________, together with interest thereon at the legal or agreed rate.

__________
Lien Claimant

By __________

STATE OF __________

__________* County of __________

I, __________, being of lawful age and being first duly sworn upon oath, do say that I am __________ of the Lien Claimant herein named; that I have read the within Statement of Mechanics' Lien and know the contents thereof; and that the same is true and correct, to the best of my knowledge, information and belief, and is made on behalf of the Lien Claimant.

Subscribed and sworn to before me in the __________ County of __________ State of __________ this __________ day of __________, 20__________.

Witness my hand and official seal.

__________
Notary Public

My commission expires: __________

*Insert "City and" when applicable

Name and Address of Person Creating Newly Created Legal Description (§38-35-106.5, C.R.S.)

notice of intent to file a lien statement

TO THE OWNER AND TO THE PRINCIPAL CONTRACTOR:

Take Notice that the Lien Claimant set forth on the Statement of Lien contained on the reverse of this Notice claims a Mechanics' Lien for laborers or material or equipment supplied to, or labor performed on, the project situate upon the real property...