PLEASE FILL OUT THE FOLLOWING FORM AS COMPLETELY AS POSSIBLE.  AFTER SUBMITTING THE FORM YOU WILL BE TRANSFERRED TO A PAGE FOR COMPLETION OF YOUR TRANSACTION.

Filing State
YOUR (LIENOR) CONTACT DETAILS
Name of Lienor	*
Street Address of Lienor	*
Suite (if applicable)
City	*
State	*	- - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip / Postal	*
Phone Number	*
Fax
E-mail Address	*
Contact Person (IF DIFFERENT FROM ABOVE)
DISCHARGE INFORMATION
If you have a scanned copy of your lien, you may upload it here. If a file is uploaded no further information about the lien is necessary unless specifically requested by LienitNow.com.
Work Performed For		Please Choose... Tenant Property Owner
Name and address of the entity with whom you have a contract for this project
If known, exact address of jobsite to be liened (include store name, tenant name, floor #, apt #, jobsite block and lot)
If known, name and address of the property owner for whom the project is being performed
County Lien Was Recorded
Date Lien Was Recorded
Book and Page number recorded on lien (if applicable)
LIEN VALUE
AMOUNT OF FILED LIEN	*
DISCHARGE AUTHORIZATION AND SUBMISSION
Name of duly authorized company officer entitled to sign discharge of lien	*
Position with Company
DO YOU AUTHORIZE LIENITNOW.COM TO ACT AS YOUR AGENT TO FILE THE DISCHARGE?	*	Yes No
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This purchase is non-refundable. By choosing yes in the field to the right and pressing submit below, you agree that LienItNow.com’s liability is limited and that you have read and agree with the terms and conditions of LienItNow.com's legal disclaimer. For more information, please read the Legal Disclaimer associated with this site.	*	Yes
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