Fill and Sign the Lien New York Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _____________________ Company: _____________________ Address: _______________________ City: ____________________ State: _____ Zip: _________ Phone: _________________ Fax: ___________________ EXTENSION OF NOTICE OF MECHANIC’S LIEN (Individual) TO THE CLERK OF __________________ COUNTY, STATE OF NEW YORK AND ALL OTHERS WHOM IT MAY CONCERN: PLEASE TAKE NOTICE, that ______________________________ , lienor, residing at or having a principal place of residence at ________________________ , in the County of __________________ , State of New York, pursuant to Section 17 of the Lien Law of the State of New York, hereby extends for a period of one year from the filing hereof, that certain Notice of Lien filed in this office by said Lienor on __________________ , against the real property located in __________________ , in the Town of __________________ , County of __________________ , State of New York, and being shown on the __________________ County Tax Map in Section ____________ , Block ____________ , Lot ____________ and being more particularly bounded and described as follows:       Extension of Notice of Mechanic’s Lien Page 1 of 2 The owner of said real property against whose interest therein the lien is claimed is ______________________________ and the name of the contractor is ______________________________ . The amount of said lien is $ ____________ . The above name lienor requests that, pursuant to Section 17 of the Lien Law of the State of New York, the aforementioned lien be re-docketed as of the date of the filing of this extension. Dated: __________________ ______________________________ Signature of Lien Holder _____ _________________________ Type or Print Name 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: _____________________ Extension of Notice of Mechanic’s Lien Page 2 of 2