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.

YOUR (LIENOR) CONTACT DETAILS
Filing State
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)
LIEN INFORMATION
Work Performed For	*	Please Choose... Tenant Property Owner
Name and address of the entity with whom you have a contract for this project	*
What is your relationship to this project	*	Please Choose... Contractor Subcontractor Sub-subcontractor Supplier
If your answer to the question above is sub-subcontractor, enter the name and address of the prime contractor.
Was the work done pursuant to a written contract, purchase order, exchange of written correspondence, or delivery tickets?	*	Yes No
Date of Contract
Describe the materials you furnished and the work you performed on the project	*
First Date You Provided LABOR AND/OR MATERIALS
Last date you provided LABOR AND/OR MATERIALS	*
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
If known, the name and address of the project lender
LIEN VALUE COMPUTATION (Please do not use commas)
CONTRACT AMOUNT
SIGNED CHANGE ORDER ADDITIONS
SIGNED CHANGE ORDER DEDUCTIONS
VALUE OF WORK STILL TO BE COMPLETED (if applicable)
PAYMENTS MADE TO YOU
BALANCE DUE (click in this field to automatically calculate)
LIEN AUTHORIZATION AND SUBMISSION
Name of duly authorized company officer entitled to sign lien	*
Position with Company
DO YOU AUTHORIZE LIENITNOW.COM TO ACT AS YOUR AGENT TO FILE THE LIEN?	*	Yes No
How did you hear about us? If your answer is the Internet please let us know the search engine in which you found our site.
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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