Preliminary Lien Notice
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Please note that ___________________
Whose address is at:
________________________________
City: ____________________________
County: __________________________
State: ___________________________
Zip: _____________________________
Has furnished or will furnish labor, service, equipment or material to the work of improvement that is at the following location:
Address:
________________________________
City: ____________________________
County: __________________________
State: ___________________________
Zip: _____________________________
Work Tasks:
________________________________
________________________________
________________________________
________________________________
Claimant Signature
The name and address of the person or business that contracted for the labor, services, and / or equipment as listed above is:
Name: ___________________________
Address: _________________________
City: ____________________________
County: __________________________
State: ___________________________
Zip: _____________________________
This preliminary lien notice is being served on the following persons and business entities at the listed addresses:
[ ] Owner
Name: ____________________
Address: __________________
[ ] Original Contractor
Name: ____________________
Address: __________________
[ ] Construction Lender
Name: ____________________
Address: __________________
[ ] Insurer
Name: ____________________
Address: __________________
[ ] Trust
Name: ____________________
Address: __________________
[ ] Subcontractor
Name: ____________________
Address: __________________
The estimated price of the labor, services, equipment or materials described above is:
$__________
Preliminary Lien Notice
I, _________ do hereby declare that I have served copies of the above Preliminary Lien Notice:
[ ] By personally delivering copies to (the name and title of person served the lien notice)
________________________________
at the following address: __________________
on ____/____/______ at ____:______ AM / PM.
[ ] By First Class Certified or Registered Mail Service with postage prepaid and addressed to each of the above listed parties at their address shown above on ____/____/______.
I declare under the penalty of perjury that the foregoing is true and correct.
_______________________ Date_____
Signature
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