City/ Public Improvement

Lien Questionnaire

A Notice of Lien on Account of Public Improvement must be filed within 30 days of completion and acceptance by the city agency. To file your lien, fill out this lien questionnaire.

Name of Your Company

Contact Name

First Name

Last Name

You will receive your lien via email

Your Business Address

(No PO Boxes)

Your Phone #

(###)

###

####

Full name of person signing lien

First Name

Last Name

Title of person signing lien

Name of contractor that hired you

Address of contractor that hired you

Name of prime contractor

(If you are a sub to a subcontractor)

Address of prime contractor

(if you are a sub to a sub-contractor)

City Agency

Name of the city agency that owns the project

Project Name & Description

Project Address

The exact address where you did the work

Contract Number

Date when monies became due

YYYY

County in which work was performed

Describe the labor performed

Describe the materials provided

Describe the materials manufactured that were not put in the job

The agreed price and value of the labor performed (include both paid and unpaid labor)

The agreed price and value of the materials provided (include both paid and unpaid materials)

Total agreed price and value of the contract

The amount unpaid for labor performed

The amount unpaid for materials provided

The amount unpaid for materials manufactured but not delivered

What is the total amount of lien?

First date you performed labor

YYYY

First date you provided materials

YYYY

Last date you performed labor

YYYY

Last date you provided materials

YYYY

City/ Public Improvement

Lien Questionnaire

Leonard J. Catanzaro | Attorney at Law