B. MATERIAL OR LABOR INFORMATION:
LIEN & BOND PROTECTION FORM
Please proceed with (check one or more of the following):
Preliminary Notice/Intent to Lien
Yes
No
Mechanic's Lien and/or Bond Claim, Stop Notice, Miller Act
Investigate Lien/Bond Right
Collection and/or Legal Action (at Reduced Rates)
Is account past due?
Date
Project Location
(State)
A. CLAIMANT INFORMATION:
Address:
1. Your company's exact corporate Name:
City:
State:
Zip:
2. Tel:
Fax:
State of incorporation:
3. Your Customer's Name:
Your Reference No.:
Customer Address:
1. Did you furnish:
material
labor
both
2. Date of P.O./Contract:
3. Brief Description of what your company furnishes:
4. Actual and/or estimated dates materials/labor has or will be furnished (for TX, provide statement of account.)
First:
Last:
Ongoing?
Yes
No
5. Total Invoices:
Amt. Paid:
Balance:
C. PROJECT INFORMATION:
Private
Public
Commercial
Residential
(Please check all that apply)
1. Project (jobsite) Name:
Address:
2. Project Owner/Lessee:
Tel:
Address:
3. Gen. Contr./Const. Mgr.:
Tel:
Address:
4. Subcontractor:
Tel:
Address:
5. Sub-subcontractor:
Tel:
Address:
6. Construction Lender:
Tel:
Address:
7. Bonding Co./Agent:
Tel:
Address:
Bond No.:
Project No.:
D. MISCELLANEOUS:
1. Please attach any of the following if available to you:
Statement/Invoices
Preliminary Notices
Proof of Delivery
Contract/Purchase Order
Copy of Bond
Notice of Commencement
2. The undersigned authorizes the filing of a Lien or Claim on behalf of the said claimant. It is the responsibility of the undersigned to ensure accuracy of information and sufficient time allowance for filing. LienMaster or local counsel are not responsible for any inaccurate information provided, lack of information, or insufficient time allowance for filing.
Name/Title Submitted by:
Date:
(Will be used to send you an E-mail confirmation only)
E-mail:
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