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Fill and Sign the Georgia Filing Claim Form

Fill and Sign the Georgia Filing Claim Form

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DEMAND FOR FILING CLAIM OF LIEN TO POTENTIAL LIEN CLAIMANT ON NON-RESIDENTIAL PROPERTY - INDIVIDUAL TO: ________________________________ ________________________________ ________________________________ ________________________________ 1. A Preliminary Lien Notice wa s filed with the Clerk of Superior Court of the County in which the subject real estate is located within 30 days after the Claimant: ( ) delivered materials ( ) provided any labor or services, for which a lien may be claimed. (check all that apply) 2. The name, address, and telephone number of the potential lien claimant are: _________________________________________ _________________________________________ _________________________________________ _________________________________________ 3. The name and address of the contractor or other person at whose instance the labor, services, or materials were furnished is/are: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ 4. The name of the owner of the real estate is: __________________________________ . 5. A description sufficient to identify the real estate against which the lien is or may be claimed is: ________________________________________ . Demand for Filing Claim of Lien Page 1 of 3 6. A general description of the labor, services, or materials furnished or to be furnished is as follows: __________________________________________________________________ ______________________________________________________ 7. The property is located in _____________________ County, Georgia and has a common address of ___________________________________________________________ 8. This demand was mailed to you on __________________________________ pursuant to Code Section 44-14-361.4. You are notified that unless you file a claim of lien with respect to this claim on or before the tenth day after said date of mailing your right to claim a lien will be dissolved. 9. A true and correct copy of the Preliminary Lien Notice filed by you is attached hereto as Exhibit "A" and incorporated herein by reference. 10. Please take notice that the preliminary notice of lien rights filed by you dated _________________________________ shall expire and be dissolved if at least ten days have elapsed since the date of this mailing and you have not filed a claim of lien. 11. To the knowledge of the undersigned, this demand for filing of a claim of lien has not been sent without Contractor's contract being substantially complete, or without the potential lien claimant's contract being terminated, or the undersigned has knowledge that potential lien claimant has abandoned the contract. DATED this the _____ day of __________________ , 20 _____ . ____________________________________ Signature _____ _______________________________ Type or Print Name Demand for Filing Claim of Lien Page 2 of 3 Affidavit of Service State of ________________ County of ____________________ I, ________________________________ , hereby certify that I have this date sent a true and correct copy of this ______________________________________ by certified mail, return receipt requested, registered mail, return receipt requested, statutory overnight delivery, acknowledging delivery signed by addressee or agent of addressee requested, in accordance with law, to the address of the potential lien claimant specified in the preliminary notice of lien rights , which the name and address are as follows: __________________________________ __________________________________ __________________________________ __________________________________ DATED this the ______ day of __________________ , 20 ______ . _____________________________ Signature _____ ________________________ Type or Print Name Reference 44 - 14 - 361.4. Demand for Filing Claim of Lien Page 3 of 3

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