Fill and Sign the Lien Holder Form Ny

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _________________ Company: _________________ Address: _________________ City: _______________ State: _____ Zip: _______ Phone: _______________ Fax: _______________ Notice of Lien – Individual (N.Y. Lien Law § 9) COMES NOW, _________________________________ , as a party who has provided labor or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , and would provide notice of the following: 1. The undersigned lien claimant, _________________________________ , may be reached at the following mailing address, _______________________________________________________________________ , or, if applicable, through the undersigned’s attorney of record, _________________________________ , whose address is _______________________________________________________________________ . 2. On information and belief the undersigned would state that the above described property is owned by _________________________________ , whose interest in the property, if known, is that of _______________________________________________ . 3. The undersigned provided the following labor and/or materials at the following agreed price, or value thereof, under an agreement with __________________________________ . Labor/Material Provided Agreed Price or Value ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Notice of Lien Page 1 of 2 ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ . 4. The amount currently unpaid to the undersigned for said labor and/or materials is $ ______________ . 5. Said labor and materials were first provided on the ____ day of _____________ , 20 ______ , and were last provided on the _____ day of _______________ , 20 ______ . This the _____ day of _______________ , 20 _______ . ______________________________ Signature _____ _________________________ Type or Print Name I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Notice of Lien are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant STATE OF NEW YORK COUNTY OF _________________ On the _____ day of ______________ in the year ___________ before me, the undersigned, personally appeared __________________________________ , personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity (ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _______________ Notice of Lien Page 2 of 2