Fill and Sign the New Jersey Lien 497319195 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-- CORPORATION--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.), 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 ___________________________________ Name of Claimant ____________________________ ____________________________________ Witness Signature ____________________________ __________________________________ Witness Title _____ _________________________ 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 Notice of Unpaid Balance and Right to File Lien. 2. The work, services, material or equipment for which this 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 Notice of Unpaid Balance and Right to File Lien. 3. The 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. This the ______ day of ____________________, 20____. ___________________________________ Name of Claimant ____________________________________ Signature _____ _______________________________ Title Amended Notice of Unpaid Balance Page 3 of 4 _____ ______________________________ Type or Print Name and Title Acknowledgment of Corporation State of New Jersey, County of ____________________ , ss: I CERTIFY that on ________________ , ______ , ________________________________ personally came before me and this person acknowledged under oath, to my satisfaction, that: (a) this person is the ___________________________________ of the corporation named in this document; (b) this document was signed and delivered by the corporation as its voluntary act duly authorized by a proper resolution of its Board of Directors; (c) this person knows the proper seal of the corporation which was affixed to this document; and (d) this person signed this proof to attest to the truth of these facts. ______________________________ Name Title: _________________________ Signed and sworn to before me on ________________ , ___________ . ______________________________ Notary Public Print Name: ___________________ My commission expires: ________________ NJ § 2A: 44A-20 Amended Notice of Unpaid Balance Page 4 of 4