Fill and Sign the Public Improvement Liens Wisconsin Department of Form

Claim for Public Improvement Lien Page 1 of 2 CLAIM FOR PUBLIC IMPROVEMENT LIEN – CORPORATION (§779.15, Wis. Stats.) CLAIMANT _______________________________ Name: _______________________________ Address: ___________________________________________________________ PRIME CONTRACTOR ___________________________________ Name: ___________________________________ Address: ___________________________________ PUBLIC ENTITY ___________________________________ PROJECT NUMBER (if any)___________________________________ LOCATION OF PUBLIC IMPROVEMENT PROJECT _______________________________________________________________________ DESCRIPTION OF LABOR AND/OR MATERIALS FURNISHED BY CLAIMANT ________________________________________________________________________________________________________________________________________________________________________________________________________________________ AMOUNT CLAIMED $ ________________ INSTRUCTIONS TO THE PUBLIC ENTITY: Pursuant to §779.15(1), Wis. Stats., to the extent money, bonds or warrants are due or will be due the Prime Contractor upon receipt of this notice, and this claim is admitted by the Prime Contractor OR the Prime contractor does not dispute the claim within thirty (30) days after service, (a) payment shall be made to the Claimant in the amount claimed on demand and charged to the Prime Contractor, or (b) if amounts claimed exceed the amounts due to the Prime Contractor, notify the Claimant and the Prime Contractor in writing of who is entitled to the available money and payment of that amount shall be made unless an action is commenced within twenty (20) days of the mailing of the determination of entitlement. This the _____ day of ______________, 20___________. ______________________________ Signature______________________________ Type or Print Name______________________________ Title______________________________ Corporation Claim for Public Improvement Lien Page 2 of 2 Certificate of Delivery I, _________________________________, hereby certify that I have delivered this day a true and correct copy of the foregoing to clerk, treasurer or state agency, or to the prime contractor, ___________________________________ by: ( ) Mailing a true and correct copy of same by registered U.S. mail, postage prepaid, return receipt requested to __________________________________. So certified this the _____ day of _________________, 20______. ________________________ Signature