REQUEST FOR CLAIM OF LIEN Please prepare for our representative’s signature, a Claim of Lien in accordance with the following information, which you may rely on, and at your customary rates of charge. 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: $______________________________ 7. Job name, address, and legal description: ____________________________ ______________________________________________________________ ______________________________________________________________ 8. A NOTICE TO OWNER was served on (date) ________________. (attached 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: ________________________________________________________________________ CITY:
TELEPHONE: ________________________ FAX: _________________________________ SIGNATURE: _______________________________________ DATE: _________________ PRINTED SIGNATURE: _______________________________________________ |
