Fill and Sign the North Carolina Claim Form

NOTICE OF CLAIM OF LIEN BY FIRST, SECOND OR THIRD TIER SUBCONTRACTOR - INDIVIDUAL (N.C. Gen. Stat. § 44A-19) To: 1. ______________________________________________________________________ _______________________________________________________________________ , owner of property involved. (Name and address) 2. ______________________________________________________________________ _______________________________________________________________________ , general contractor. (Name and address) 3. ______________________________________________________________________ _______________________________________________________________________ , first tier subcontractor (Name and address) against or through whom subrogation is claimed, if any. 4. ______________________________________________________________________ _______________________________________________________________________ , second tier subcontractor (Name and address) against or through whom subrogation is claimed, if any. General description of real property where labor performed or material furnished: ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ General description of undersigned lien claimant's contract including the names of the parties thereto: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________ . The amount of lien claimed pursuant to the above described contract: $ ______________ . The undersigned lien claimant gives this notice of claim of lien pursuant to North Carolina law and claims all rights of subrogation to which he or she is entitled under Part 2 of Article 2 of Chapter 44A of the General Statutes of North Carolina. Dated _______________________ ________________________ Lien Claimant _____ ____________________ Notice of Claim of Lien Page 1 of 2 Type or Print Name _____ ___________________ ________________________ (Address) Certificate of Delivery I, _____________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to ___________________________________ by: ( ) Personal Service ( ) Mailing a true and correct copy of same by certified or registered U.S. mail, postage prepaid, return receipt requested. So certified this the ______ day of ___________________, 20____. ________________________ Signature Notice of Claim of Lien Page 2 of 2