Fill and Sign the Lhwca Procedure Manual United States Department of Labor Form

Itemized Statement Page 1 of 2 Itemized Statement – Individual (N.Y. Lien Law § 38) COMES NOW, _______________________________, as a party which has provided labor and/or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________, and would state as follows: 1.On or about the _____ day of _______________ , 20______ the undersigned filed a notice of lien regarding labor and/or improvements furnished for the improvement of the above described property in the amount of $_____________.2. On or about the _____ day of ______________ , 20______, the undersigned received a demand from the property owner and/or contractor requesting an itemized statement which shall set forth the items of labor and/or material and the value thereof which make up the amount for which a lien is claimed and also the terms of the contract under which such items were furnished.3. Said itemized statement is as follows:labor/material provided date furnishedcost/value________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. The terms of the contract are: ________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________. This the _____ day of ______________, 20______ . ______________________________Signature ______________________________ Type or Print Name Itemized Statement Page 2 of 2 ____________________________________________________________Address I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Itemized Statement are true and correct to the best of my knowledge, information, and belief. ________________________Affiant