Notice of Unpaid Balance Page 1 of 4
Prepared by, recording requested by
and return to:
Name: _______________________
Company: _____________________
Address: ____________________
City: _________________
State: _____ Zip: __________
Phone: _______________
Fax: _______________
----------------------Above this Line for Official Use Only---------------------
NOTICE OF UNPAID BALANCE AND RIGHT TO FILE LIEN--INDIVIDUAL--
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:
Notice of Unpaid Balance Page 2 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.
Notice of Unpaid Balance Page 3 of 4
This the _____ day of ________________, 20______.
Witnessed or Attested by:
____________________________ ____________________________ (Seal)
Lien Claimant
____________________________ ____________________________ 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.
Notice of Unpaid Balance Page 4 of 4
DATED this the _____ day of _____________, 20______.
______________________________
Name of Claimant _____________________________
Signed ____________________________
Type or Print Name
State of New Jersey
County of ______________, ss:
I CERTIFY that on _______________, ________,
__________________________________ personally came before me and acknowledged
under oath to my satisfaction, that this person (or if more than one, each person):
a) is named in and personally signed the attached document; and
b) signed and delivered this document as his/her/their act and deed; and
c) executed this document under oath after being duly sworn.
______________________________
Claimant ______________________________
Notary Public
Print Name: ___________________
My commission expires:___________________
NJ § 2A: 44A-20