Fill and Sign the New Jersey Lien 497319194 Form

Prepared by, recording requested by and return to: ----------------------Above this Line for Official Use Only---------------------Name: _______________________ Company: _____________________ Address: ____________________ City: _________________ State: _____ Zip: __________ Phone: _______________ Fax: _______________ AMENDED NOTICE OF UNPAID BALANCE AND RIGHT TO FILE LIEN-- INDIVIDUAL--RESIDENTIAL TO THE CLERK, COUNTY OF ________________ : In accordance with the terms and provisions of the "Construction Lien Law," P.L.1993, c.318 (C.2A:44A-1 et al.), an amended notice is hereby given that: 1. _______________________________ (Name of Claimant) of _____________________________________________________________________ (address of claimant) has on the _____ day of ______________ , 20 _______ , a potential construction lien against the below described property of ___________________________________ (owner against whose property the lien will be claimed), in the amount of $ ____________ , for the value of the work, services, material or equipment provided in accordance with a contract with _________________________________________ (name of contracting party with whom claimant has a contract) for the following work, services, materials or equipment: a. __________________________________________________________________ _____________________________________________________________________ b. __________________________________________________________________ _____________________________________________________________________ c. __________________________________________________________________ _____________________________________________________________________ 2. The amount due for work, services, materials or equipment provided by claimant in connection with the improvement of the real property, and upon which this lien claim is based is as follows: Amended Notice of Unpaid Balance Page 1 of 4 Total contract amount: $ ____________ Amendments to contract: $ ____________ Total contract amount and amendments to contract: $ ____________ Less: Agreed upon Credits $ ____________ Contact amount paid to date: $ ____________ Amendments to the Contract paid to date: $ ____________ Total Reductions from Contract amount and amendments to contract $ ____________ TOTAL LIEN AMOUNT $ ____________ 3. This construction lien is to be claimed against the interest of ________________________________ as: Owner, Lessor or Other: ________________________________ (describe) in that certain tract or parcel of land and premises described as Block __________ , Lot ___________ , on the tax map of the ________________________________ of ________________________________ , County of ________________ , State of New Jersey, for the improvement of which property the aforementioned work, services, materials or equipment was provided. 4. The work, services, materials or equipment was provided pursuant to the terms of a written contract (or, in the case of a supplier, a delivery or order slip signed by the owner, contractor, or subcontractor having a direct contractual relation with a contractor, or an authorized agent of any of them), dated the _____ day of ________________ , 20 ______ , between ________________________________ (claimant) and _________________________________ (name of other contracting party) of ________________________________________________________________________ (address). 5. The date of the provision of the last work, services, material or equipment for which payment is claimed is the _____ day of _______________ , 20 ______ . 6. The written contract is/ is not a residential construction contract as defined in section 2 of this act. 7. This notification has been filed prior or subsequent to completion of the work, services, materials or equipment as described above. The purpose of this notification is to advise the owner and any other person who is attempting to encumber or take transfer of said property described above that a potential construction lien may be filed within the 90 day period following the date of the provision of the last work, services, materials or equipment as set forth in paragraph 5. Amended Notice of Unpaid Balance Page 2 of 4 This the _____ day of ________________ , 20 ______ . Witnessed or Attested by: ____________________________ ____________________________ (Seal) Lien Claimant ____________________________ _____ _______________________ Type or Print Name CLAIMANT'S REPRESENTATION AND VERIFICATION Claimant represents and verifies that: 1. The amount claimed herein is due and owing at the date of filing, pursuant to claimant's contract described in the Amended Notice of Unpaid Balance and Right to File Lien. 2. The work, services, material or equipment for which this Amended Notice of Unpaid Balance and Right to File Lien is filed was provided exclusively in connection with the improvement of the real property which is the subject of this Amended Notice of Unpaid Balance and Right to File Lien. 3. The Amended Notice of Unpaid Balance and Right to File Lien has been filed within 90 days from the last date upon which the work, services, materials or equipment for which payment is claimed was provided. 4. The foregoing statements made by me are true, to the best of my knowledge. Amended Notice of Unpaid Balance Page 3 of 4 DATED this the ______ day of _________________, 20____. ______________________________ Name of Claimant _____________________________ Signed _____ _______________________ Type or Print Name State of New Jersey County of ____________________ , ss: I CERTIFY that on _______________ , __________ , ___________________________________ personally came before me and acknowledged under oath to my satisfaction, that this person (or if more than one, each person): a) is named in and personally signed the attached document; and b) signed and delivered this document as his/her/their act and deed; and c) executed this document under oath after being duly sworn. ______________________________ Claimant ______________________________ Notary Public Print Name: ___________________ My commission expires: ________________ NJ § 2A: 44A-20 Amended Notice of Unpaid Balance Page 4 of 4