Fill and Sign the Mechanics Lien Document Form

Construction Lien Questionnaire Form Client Information Legal name of company claiming the lien:       Company formation: Sole Proprietorship Partnership Corporation State of incorporation:       Current address:       County where office located:       Contact person and telephone number:       Who will sign the lien (preferably an owner, partner or officer of the corporation)?:       Title:       Name of prime contractor:       Street:       City:       State:       Zip:       Contract Information Name of owner of the premises:       Street:       City:       State:       Zip:       Current property owner(s) address if different:       Original Contract Amount: $       Do you have a signed contract? Yes No If yes, who signed the contract?       Payment date(s) in the contract:       Extras: $       Amount(s) Paid to Date: $       If applicable: Mechanic’s lien date:       Lis pendens date:       Waivers:       Please attach copies of any Agreements, Contracts, Invoices, Change Orders, Lien Waivers, Pre-Lien Notice and any other information that may be helpful. Consumer rights pamphlet provided: Yes No Consumer Rights Acknowledgement Form Executed: Consumer rights pamphlet provided: City agency involved:       Work Performed Information Legal description of property where work was performed:       County where property is located:       Street address of the property:       Dollar amount of claim (list interest or finance charges separately and do not include any amounts for work not yet performed):       First date work performed (including delivery of equipment and materials):       Last date work performed (not including warranty work):       Name and employer of person that directed you to do the work:       Address:       Telephone:       Name(s) of any bank(s) financing the construction, if known:             Brief description of work/improvements you provided to the property:       Was pre-lien notice given to the property owner before beginning work?: Yes No WHAT IS YOUR PREFERENCE FOR VERIFICATION OF INFORMATION?: VERIFY ONLY PROPERTY OWNERSHIP AND LEGAL DESCRIPTION; ALL OTHER INFORMATION SHALL BE RELIED UPON AS STATED ABOVE. VERIFY ONLY THE FOLLOWING INFORMATION:       ALL OTHER INFORMATION SHALL BE RELIED UPON AS STATED ABOVE.