Commercial Lien Questionnaire

A mechanic's lien on a commercial job must be filed with the County Clerk's office within eight (8) months from the last date work was performed or materials were provided. To file your lien, fill out this lien questionnaire and hit “send form”. You will be requested to enter your credit card information on our secure payment gateway, and be billed $385, calculated as follows: $350 - attorney's fee; $35 court filing fee. For more information on how this service works, please click here.

Your Info:

Your Company Information
Name of your company:
Contact Name:
Email Address:
I prefer to receive my lien via:	Email Fax

Your Mailing Address (no PO Boxes)
Street:
City:
State:	AL AK AZ AR CA CO CT DE DC 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:
Phone number:
Fax number:
Cell number:

 

Signer's Info:

Full name and title of person signing lien:
Name:
Title:	President Vice-President Partner Managing Member Sole-Proprietor Other

 

Contractor(s) Info:

Contractor's Name and Address
Name of contractor that hired you:
Street:
City:
State:	AL AK AZ AR CA CO CT DE DC 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:

Prime Contractor's Name and Address (If you are a sub to a sub-contractor)
Name of prime contractor:
Street:
City:
State:	AL AK AZ AR CA CO CT DE DC 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:

 

Jobsite:

Job Site Location
The exact address where you did the work:
County in which the work was performed:	Bronx Kings (Brooklyn) New York (Manhattan) Queens Richmond (Staten Island) Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings (Brooklyn) Lewis Livingston Madison Monroe Montgomery Nassau New York (Manhattan) Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond (Staten Island) Rockland Saratoga Schenectady Schoharie Schuyler Seneca Steuben St. Lawrence Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates

Owner's Name and Address
Name of owner of the premises:
Street:
City:
State:	AL AK AZ AR CA CO CT DE DC 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:

Description of Labor and Materials
Describe labor performed:
Describe materials provided:
Describe materials fabricated that were not put in the job:
The agreed price and value of the labor performed (include both paid and unpaid labor):	$
The agreed price and value of the materials provided (include both paid and unpaid materials):	$
The agreed price and value of the materials actually manufactured but not delivered to the real property (include both paid and unpaid materials not delivered):	$
Total agreed price and value of the contract:	$
The amount unpaid for labor performed:	$
The amount unpaid for materials provided:	$
The amount unpaid for materials manufactured but not delivered:	$
What is the total amount of lien:	$

First and Last Dates Labor Performed and Materials Provided
First date you performed labor:	/ /
First date you provided materials:	/ /
Last date you performed labor:	/ /
Last date you provided materials:	/ /