Fill and Sign the Wisconsin Public Lien Form

CLAIM FOR PUBLIC IMPROVEMENT LIEN -- INDIVIDUAL (§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 Claim for Public Improvement Lien Page 1 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 Claim for Public Improvement Lien Page 2 of 2