Fill and Sign the Questionnaire Form

Questionnaire Regarding Liens Client Information Legal name of company claiming the lien: Company formation: Sole Proprietorship Partnership Corporation State of incorporation: Current address: County where office located: Contact person and telephone number: Who will sign the lien (preferably an owner, partner or officer of the corporation)?:   Title: Contract Information Name of owner of the property: Street: City: State: Zip: Current property owner(s) address if different: Type of contract: Original Contract Amount: $ Extras: $ Amount(s) Paid to Date: $ Payment plan: Waivers: Please attach copies of any Agreements, Contracts, Invoices, Change Orders, Lien Waivers, Pre-Lien Notice and any other information that may be helpful. Have any notices been sent? Yes No If yes, please list notice type and date sent: Have you attempted to work out a payment plan? Yes No If yes, please describe: Other agency involved, if applicable: Other claimants involved, if applicable: Legal description of property lien is sought on: County where property is located: Street address of the property, if applicable: Dollar amount of claim (list interest or finance charges separately and do not include any amounts for work not yet performed): First date service performed (including delivery of equipment and materials): Last date service performed (not including warranty work): Name and employer of person that hired you: Address: Telephone: Name(s) of any bank(s) financing the services, if known: Storage costs to date, if applicable: