Fill and Sign the File Lien Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: ____________________ Company: ___________________ Address: ___________________ City: _________________ State: _____ Zip: __________ Phone: ________________ Fax: ________________ AMENDED NOTICE OF UNPAID BALANCE AND RIGHT TO FILE LIEN-- INDIVIDUAL TO THE CLERK, COUNTY OF __________________ : In accordance with the terms and provisions of the "Construction Lien Law," P.L.1993, c.318 (C.2A:44A-1 et al.), an amended notice is hereby given that: 1. ________________________________ (Name of Claimant) of ________________________________________________________________________ (address of claimant) has on the _____ day of _______________ , 20 ______ , a potential construction lien against the below described property of ___________________________________ (owner against whose property the lien will be claimed), in the amount of $ ______________ , for the value of the work, services, material or equipment provided in accordance with a contract with __________________________________ (name of contracting party with whom claimant has a contract) for the following work, services, materials or equipment: a. ___________________________________________________________________ ______________________________________________________________________ b. ___________________________________________________________________ ______________________________________________________________________ c. ___________________________________________________________________ ______________________________________________________________________ 2. The amount due for work, services, materials or equipment provided by claimant in connection with the improvement of the real property, and upon which this lien claim is based is as follows: Amended Notice of Unpaid Balance Page 1 of 4 Total contract amount: $ ___________ Amendments to contract: $ ___________ Total contract amount and amendments to contract: $ ___________ Less: Agreed upon Credits $ ___________ Contact amount paid to date: $ ___________ Amendments to the Contract paid to date: $ ___________ Total Reductions from Contract amount and amendments to contract $ ___________ TOTAL LIEN AMOUNT $ ___________ 3. This construction lien is to be claimed against the interest of _________________________________ as: Owner, Lessor or Other: ________________________________ (describe) in that certain tract or parcel of land and premises described as Block _________ , Lot _________ , on the tax map of the _________________________________ of ________________________________ , County of ________________ , State of New Jersey, for the improvement of which property the aforementioned work, services, materials or equipment was provided. 4. The work, services, materials or equipment was provided pursuant to the terms of a written contract (or, in the case of a supplier, a delivery or order slip signed by the owner, contractor, or subcontractor having a direct contractual relation with a contractor, or an authorized agent of any of them), dated the _____ day of _____________ , 20 ______ , between ___________________________________ (claimant) and __________________________________ (name of other contracting party) of ________________________________________________________________________ (address). 5. The date of the provision of the last work, services, material or equipment for which payment is claimed is the _____ day of ______________ , 20 ______ . 6. The written contract is/ is not a residential construction contract as defined in section 2 of this act. 7. This notification has been filed prior or subsequent to completion of the work, services, materials or equipment as described above. The purpose of this notification is to advise the owner and any other person who is attempting to encumber or take transfer of said property described above that a potential construction lien may be filed within the 90 day period following the date of the provision of the last work, services, materials or equipment as set forth in paragraph 5. Witnessed or Attested by: Amended Notice of Unpaid Balance Page 2 of 4 ____________________________ ____________________________ (Seal) Lien Claimant ____________________________ _____ ________________________ Type or Print Name CLAIMANT'S REPRESENTATION AND VERIFICATION Claimant represents and verifies that: 1. The amount claimed herein is due and owing at the date of filing, pursuant to claimant's contract described in the Amended Notice of Unpaid Balance and Right to File Lien. 2. The work, services, material or equipment for which this Amended Notice of Unpaid Balance and Right to File Lien is filed was provided exclusively in connection with the improvement of the real property which is the subject of this Amended Notice of Unpaid Balance and Right to File Lien. 3. The Amended Notice of Unpaid Balance and Right to File Lien has been filed within 90 days from the last date upon which the work, services, materials or equipment for which payment is claimed was provided. 4. The foregoing statements made by me are true, to the best of my knowledge. This the ______ day of ____________________, 20____. ______________________________ Name of Claimant _____________________________ Signed _____ ________________________ Type or Print Name Amended Notice of Unpaid Balance Page 3 of 4 State of New Jersey County of _______________ , ss: I CERTIFY that on ___________________ , ___________ , __________________________________ personally came before me and acknowledged under oath to my satisfaction, that this person (or if more than one, each person): a) is named in and personally signed the attached document; and b) signed and delivered this document as his/her/their act and deed; and c) executed this document under oath after being duly sworn. _____________________________ Signature ______________________________ Notary Public Print Name: ___________________ My commission expires: _______________ NJ § 2A: 44A-20 Amended Notice of Unpaid Balance Page 4 of 4