Name of Lienor:

Street Address of Lienor:

Suite/Apt (if applicable):

City:

State (2 letter abbreviation):

Zip Code:

Phone (Format: xxx-xxx-xxxx):

Fax (Format: xxx-xxx-xxxx):

E-Mail Address :

Contact Person: (if different from above please enter your contact details including Name, Mailing Address, Phone and E-mail.)

LIEN INFORMATION
 

Work performed for:

Name and Address of the entity with whom you have a contract for this Project:

What is your relationship to this project?

If your answer to the question above is subcontractor, please supply the name and the address of the contractor.  If your answer to the question above is sub-subcontractor, enter the names and addresses of both contractor and subcontractor:

Was the work done pursuant to a written contract, purchase order, exchange of written correspondence, or delivery tickets?

Date of Contract (if applicable)
(format mm/dd/yyyy):

Describe the materials you furnished and work you performed on the Project.

Last Date of Labor and/or Materials Supplied

(format mm/dd/yyyy):

If known, exact address of jobsite to be liened (include store name, tenant name, floor #, apt. #, jobsite block & lot)

Name and address of property owner for whom the project is being performed (if known)

Name and Address of the person/company with whom you have the contract:

Base Contract Amount:

Signed Change Orders:

Adjusted Contract Price:

Payments Made to You:

Do you still have work to complete on the project?

If your answer to the above questions is yes, what is the value of work to be completed?

What is the balance due (add the contract balance to the “additions” change orders. Then subtract the “deductions” change orders, “payments” made, and the value of the work to be completed on the project)

Name and title of duly authorized company officer entitled to sign lien:

DO YOU AUTHORIZE NJLIEN.COM TO ACT AS YOUR AGENT TO FILE THE LIEN?           

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