# Request for Claim of Lien

## Request for Claim of Lien

- 1. Date of first furnishing of labor/materials to jobsite by undersigned
- 2. Date of last furnishing of labor/materials to jobsite by undersigned
- 3. Our direct customer is
- Address
- 4. The nature of the services, labor and/or materials furnished by us (If this is for specially fabricated materials, be sure to seek specific advice.)
- 5. Total value of what we furnished (do not include the value of work not done)
- 6. Balance owing for what we furnished (Do not include costs not directly for improving the property. You may include unpaid finance charges.)
- 7. Owner’s Name
- Owner’s Address
- Project or Job Name
- Specific Job Address
- Legal Description (If more space is needed, attach description)
- Attach description
- 8. County of the Property/Project
- 9. A NOTICE TO OWNER was served on (date)
- Attached copy, with the certified mail receipts
- WE HEREBY CERTIFY the above described materials were used, or labor and services were performed, in the improvement of the real property named above; that no waiver or release of lien rights have been executed for the sums claimed; that all the above stated information is true and correct; that a proper license is held for the work claimed by the Lienor; and that if I am not dealing directly with owner, the owner/contractor agreement is for more than $2500.00.
- FIRM NAME
- ADDRESS
- EMAIL ADDRESS
- CITY
- STATE
- ZIP
- TELEPHONE
- FAX
- DATE
- Website

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Michael Garcia, P.A. — [https://gpacmpdev.wpenginepowered.com/lien-request/](https://gpacmpdev.wpenginepowered.com/lien-request/)