Thank you!

Your message has been submitted

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 PDF, JPG, PNG, DOC — up to 2 MB

8. County of the Property/Project

9. A NOTICE TO OWNER was served on (date)

Attached copy, with the certified mail receipts PDF, JPG, PNG, DOC — up to 2 MB

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

754-254-1100