Wyoming — 29-10-104. Form for lien statement.

(a)The lien statement shall be filed with the county clerk's office in the county where the property against which the lien is filed is located and shall be completed in substantially the following form:

Note to lien claimant: This form, if filled out correctly and filed with the county clerk's office within the time periods specified in W.S. 29-2-106 constitutes prima facie evidence that you have provided the content of the lien statement required by W.S. 29-1-312(b) and (f). If you have any questions regarding how to fill out this form or whether it has been filled out properly, you should consult an attorney.

STATE OF _____________ )

) ss.

COUNTY OF _____________ )

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: 1. Name and address of lien claimant:

______________________________

2. The amount claimed to be due and owing: $____________, 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:

______________________________

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 secured by the lien:

______________________________

6. The lien claimant last performed work, or furnished materials, for which the lien claimant asserts a lien on the ______ day of ______________, 20___.

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:

___________________________________________________

A copy of the written contract, if applicable, is located at the following address:

______________________________

DATED this ______ day of ______________, 20___.

Name of lien claimant: ______________________________

By: ______________________________

Signature: ______________________________

Title: ______________________________

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.

(Alternative 1:)

STATE OF __________________ )

) ss. COUNTY OF __________________ )

On this _____ day of ______________, 20___, subscribed and sworn to before me personally appeared ______________________________ (name of signatory), 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 the ______________________________ (title, position or type of authority granted by lien claimant) 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.

Witness my hand and official seal.

______________________________

Notarial officer

My Commission Expires:

Seal:

(Alternative 2:)

STATE OF __________________ )

) ss.

COUNTY OF __________________ )

On this _____ day of ______________, 20___, subscribed and sworn to before me personally appeared ______________________________ (name of signatory), 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 the lien statement to be the free act and deed of the lien claimant.

Witness my hand and official seal.

______________________________

Notarial officer My Commission Expires:

Seal: