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Residential, Condominium, and Cooperative Apartment Lien Questionnaire

Name of your company:
Contact:
Email Address:
I prefer to receive my lien via:

Mailing Address (no PO Boxes)
Street:
City:
State:	Zip:
Telephone number:
Fax number:
Full name and title of person signing lien:
Name of contractor that hired you:

Contractor's Address
Street:
City:
State:	Zip:
The exact address where you did the work:
County in which the work was performed:	Other

Prime Contractor's Name and Address (If you are a sub to a sub-contractor)
Name of prime contractor:
Street:
City:
State:	Zip:

Owner's Address
Name of owner of the premises:
Street:
City:
State:	Zip:
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 date you performed labor:
First date you provided materials:
Last date you performed labor:
Last date you provided materials: