Fill and Sign the Request Lien Form 497322238

REQUEST FOR LIEN INFORMATION - INDIVIDUAL (Ohio Revised Code Section 1311.011(B)(8)) State of Ohio County of _________________ ___________________________________ , whose address is ___________________________________________________________________________ , being first duly sworn, states: 1. Whereas it has come to the attention of ___________________________________ [Contractor or Lending Institution] _________________________________ that a dispute has arisen regarding the amount due and owing to subcontractor, material supplier, or laborer, ___________________________________ , by the original contractor, _________________________________ , and 2. Further, that above named subcontractor, material supplier, or laborer, has refused to supply a lien release to the original contractor, owner, part-owner, lessee, or lending institution as a result of this dispute, 3. That pursuant to Ohio Revised Code 1311.011(B)(8) the owner, part owner, or lessee shall withhold the amount of disputed payment from the contractor until such time as a lien release is obtained or the subcontractor, material supplier, or laborer gives written notice to the owner, part-owner, lessee, or lending institution that the amount of money claimed to be due has been paid, or the original contractor provides the subcontractor, material supplier, or laborer with a bond in the amount claimed by subcontractor, material supplier, or laborer. 4. That pursuant to Ohio Revised Code 1311.011(B)(8) the Contractor or Lending Institution hereby give notice to the subcontractor, material supplier, or laborer that they have ten (10) days from receipt of this notice to respond in writing and advise of the amount due and the last date the subcontractor, material supplier, or laborer performed any labor or work or furnished any material to the owner or contractor. Request for Lien Information Page 1 of 3 5. Failure to respond within ten days shall result in the information required regarding the amount due and the last date of work being supplied to the owner and lending institution by the original contractor. THIS the _____ day of _________________ , 20 ______ . By: ___________________________________ Type or Print Name: _____ _________________ Witness: __________________________________ Witness: __________________________________ This instrument was prepared by __________________ (name). Acknowledgment of Individual STATE OF OHIO COUNTY OF _____________________ The foregoing instrument was acknowledged before me this _____________________ (date) by _________________________________________ (name of person acknowledged.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: _____________________ ACKNOWLEDGED, SWORN TO AND SUBSCRIBED before me on this the _______ day of _____________________, _________. ____________________________________ Notary Public Request for Lien Information Page 2 of 3 My Commission Expires: ________________ Request for Lien Information Page 3 of 3