Note to lien claimant: Signing this form has legal implications. This form, if filled out correctly and sent within
the time periods specified in W.S. 29-2-112, constitutes prima facie evidence that you have provided the content
of the notice required by W.S. 29-2-112(a)(i). If you have any questions regarding how to complete this form,
or whether it has been properly completed, you should consult an attorney.
NOTICE TO OWNER
The undersigned party is providing work or materials to the property described below. Failure of payment due
and owing to a contractor, subcontractor or materialman for work performed or materials provided to the project
located on the property can result in the filing of a lien against the property. To avoid this result, when paying
for labor and materials, you may ask the contractor, subcontractor, or materialman for “lien waivers” from all
persons supplying materials or services. Failure to secure lien waivers may result in your paying for labor and
materials twice. A form of lien waiver is attached to this notice.
Contractor, Subcontractor, or Materialman Information
Phone Number: ________________________________________________________________________
Contact Person: _______________________________________________________________________
Materials Provide or Work Performed: _____________________________________________________
Street Address: ________________________________________________________________________
Legal Description: _____________________________________________________________________
The filing of any lien can have significant legal ramifications to both the claimant and property owner. Timely and accurate filing of all forms is
essential to securing and protecting any lien. Failure to abide by legislative requirements related to order, content and deadlines for filing said
liens may foreclose any action against the property owner. The Converse County Clerk, or any deputy thereof, cannot and will not provide you
with any advice or guidance in completion of these forms. If you have any question or concern related to the content, order or deadlines
mandated to protect your right to payment and/or lien, you should timely seek the advice of competent legal counsel.