Fill and Sign the Proof of Service of Notice of Lienindividual Form

Proof of Service of Notice of Lien Page 1 of 2Prepared by, recording requested by and return to:Name: _________________Company: _________________Address: _________________City: _______________State: _____Zip: _______Phone: _______________Fax: _______________----------------------Above this Line for Official Use Only--------------------- Proof of Service of Notice of Lien – Individual (N.Y. Lien Law § 11-b) COMES NOW, _________________________________, as a lienor, whose address is ______________________________________________________________________, and who has provided labor or materials for the improvement of the property located at and described as _______________________________________________________________________________________________________________________________________________, within five (5) days before or thirty days after filing a Notice of Lien in accordance with N.Y. Lien Law § 10 or filing an Amendment of Notice of Lien in accordance with N.Y. Lien Law § 12-a party and states the following:1.The undersigned lienor filed a Notice of Lien or an Amendment of Notice of Lien on the ____ day of _____________, 20______ . 2.The undersigned lienor served a copy of the Notice of Lien or Amendment of Notice of Lien by certified mail on _________________________________, the contractor, subcontractor, assignee or legal representative for whom the lienor was employed or to whom the lienor furnished materials, at the following address: ________________________________________________________________________or if the lienor is a contractor or subcontractor, to ___________________________________, the person, firm or corporation with whom the contract was made, at the following address: _______________________________________________________________________.3.If the undersigned lienor had a direct contractual relationship with a subcontractor or a sub-subcontractor but not with a contactor, the lienor also served a copy of the Notice of Lien or Amendment of Notice of Lien by certified mail to ___________________________________, the contractor, at the following address: _______________________________________________________________________. This the _____ day of ______________, 20______ . Proof of Service of Notice of Lien Page 2 of 2 ______________________________Signature ______________________________ Type or Print Name STATE OF NEW YORKCOUNTY 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 PublicPrinted Name: _________________ My Commission Expires: _____________________