RECORDING REQUESTED BY:  ______________________




AND WHEN RECORDED MAIL TO:  _______________________










Notice Is Hereby Given That:  _____________________


1. The undersigned is an owner or agent of an owner of the interest or estate stated below.


2. The full name of the owner is:  ___________________


3. The full address of the owner is:  ____________________


4. The nature of the interest or estate of the owner is;_____________________ in fee (If other than fee, strike "in fee" and insert, for example, "Purchaser Under Contract of Purchase," or "Lessee").


5. The full names and full addresses of all CO-owners, if any, who hold any title or interest with the above-named owner in the property are:


NAMES                                      ADDRESSES

_____________________         ____________________________________


_____________________        _____________________________________


6. A work of improvement on the property hereinafter described was completed on _______________________________.  The work done was:  _________________.


7. The name of the contractor, if any, for such work of improvement is:  __________



8. The street address of said property is:  _________________________________.


9. The property on which said work of improvement was completed is in the City of _________________________, County of ____________________, State of ______, and is described as follows:  ________________________________________.



Date:  _________________________




(Signature of Owner or Agent of Owner Named In Paragraph 2)







I, the undersigned, say:


I am the ________________________________, the declarant of the foregoing notice of completion; I have read said Notice of Completion and know the contents thereof; the same is true of my own knowledge.


I declare under penalty of perjury that the foregoing is true and correct.


Executed on ____________________, at ___________________________.