Fill and Sign the New York Assignment Form

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 ASSIGNMENT OF LIEN- INDIVIDUAL (N.Y. Lien Law § 15) The undersigned lienor __________________________________ whose address is ______________________________________________________________________ hereby provides notice to _______________________________ (owner) that on ________________ (date) he or she assigned his or her claim and lien which was recorded at __________________________________ on ________________ (date) for labor, materials, or laborers furnished for the purpose of improvements of real property to ___________________________________ whose address is ______________________________________________________________________ , the assignment to be terminated on ________________ (date) (not more than two years after the date of the assignment) . A description of the substance of the lien assigned is ________________________________________________________________________ ________________________________________________________________ , and the real property is located at (including each county name) and described as ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ , (including the name of the record owner and the location of the real estate by street and number and town or city or, if the real estate is in the city of New York, by county, except that if the real estate is in the city of New York or counties of Nassau or Onondaga, including the block in which the real estate is situated). The maximum balance of advances outstanding to be secured by the assignment is __________________ . From the date of this notice, no arrangements or payments may be made without the assignee’s consent. This the _____ day of _______________ , 20 ______ . Notice of Assignment of Lien Page 1 of 2 ______________________________ 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: _____________________ Notice of Assignment of Lien Page 2 of 2