NOTICE AND CLAIM OF LIEN REQUEST FORM by htv10612

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									□Check for Rush – A $100 fee will be incurred and the Lien will be completed within 48
hours; otherwise completed within 7 working days.

               NOTICE AND CLAIM OF LIEN REQUEST FORM
To: Van Rylin Associates – Tina Adams

●Your Company Name_________________________________________________________

●Your Company Address_______________________________________________________

●Person Requesting Lien________________Phone #_____________Fax #_______________

●Preliminary Notice Number_____________________________________________________

●Your Customer’s Name________________________________________________________

●Your Customer’s Address______________________________________________________

●Job Name __________________________________________________________________

●Job Address_________________________________________________________________

●Do you have a written contract?________________________________________________
If yes, please fax a copy of the pages that list 1) the parties involved in the contract and
the name of the job, 2) terms for payment and 3) signature page.

If No, please fax a copy of all outstanding invoices that total the dollar amount owing.

●Did you specify (by contract, invoice or agreement) an interest rate other than the
prevailing rate of 10%? If yes, what is it?__________________
●Please state your terms for payment____________________________________________
●Name and Title of an officer in your company that has knowledge of this lien

●Principal amount owing _______________________________________________________
●First date you supplied material_________________________________________________
●Last date you substantially supplied material______________________________________
(Please use completion date, not punch list date)

                      <<For Van Rylin Associates Use Only>>

Date Received:________________                    Number Assigned___________________

								
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