Fill and Sign the New York Lien Form

Assignment of Lien Page 1 of 2 Prepared by, recording requested by and return to: Name: ___________________ Company: _____________________ Address: ______________________ City: ___________________ State: _____ Zip: __________ Phone: __________________ Fax: ___________________ ----------------------Above this Line for Official Use Only--------------------- Assignment of Lien – Individual (N.Y. Lien Law § 14) COMES NOW, ________________________________, as a party who has provided labor or materials for the improvement of the property located at and described as _______________________________________________________________________________________________________________________________________________, and would state as follows: 1. On or about the _____ day of ______________, 20_______ the undersigned lien claimant, __________________________________, of the following address _______________________________________________________________________, filed a Notice of Lien regarding the above described property in the amount of $_____________. 2. Said lien is hereby expressly assigned to __________________________________, of the following mailing address, _______________________________________________________________________. This the _____ day of ________________, 20______. ______________________________ Signature______________________________ Type or Print Name I, _______________________________, do hereby swear or affirm that the matters alleged and things contained in the above Notice of Lien are true and correct to the best of my knowledge, information, and belief. ________________________ Affiant Assignment of Lien Page 2 of 2 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: ______________