Fill and Sign the New York Lien 497321238 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 Lien – Corporation (N.Y. Lien Law § 9) COMES NOW, _________________________________ , as a representative of ________________________________ a ________________________________ corporation which has provided labor or materials for the improvement of the property located at and described as ________________________________________________________________________ _______________________________________________________________________ , and would provide notice of the following: 1. The undersigned lien claimant, _________________________________ , may be reached at the following mailing address, _______________________________________________________________________ , or, if applicable, through the undersigned’s attorney of record, ________________________________ , whose address is _______________________________________________________________________ . 2. On information and belief the undersigned would state that the above described property is owned by _______________________________ , whose interest in the property, if known, is that of ____________________________________ . 3. The undersigned provided the following labor and/or materials at the following agreed price, or value thereof, under an agreement with _______________________________ . Labor/Material Provided Agreed Price or Value ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Notice of Lien Page 1 of 3 ________________________________________________________________________ _______________________________________________________________________ . 4. The amount currently unpaid to the undersigned for said labor and/or materials is $ _________________ . 5. Said labor and materials were first provided on the _____ day of _______________ , 20 ______ , and were last provided on the _____ day of _______________ , 20 ______ . This the _____ day of ______________ , 20 ______ . ________________________ Signature _____ ___________________ Type or Print Name _____ ___________________ Title _____ ___________________ Corporation Attest: Secretary 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 Notice of Lien Page 2 of 3 STATE OF NEW YORK COUNTY OF _________________ On the _____ day of _______________ in the year ____________ before me personally came __________________________________ to me known, who, being by me duly sworn, did depose and say that he/she/they reside(s) in ________________________________________________________________________ (if the place of residence is in a city, include the street and street number, if any, thereof); that he/she/they is (are) the __________________________________ (president or other officer or director or attorney in fact duly appointed) of the __________________________________ (name of corporation), the corporation described in and which executed the above instrument; and that he/she/they signed his/her/their name(s) thereto by authority of the board of directors of said corporation. ______________________________ Notary Public Printed Name: _________________ My Commission Expires: ________________ Notice of Lien Page 3 of 3