Who Hired You?

• General Contractor
• Owner
• Other/Subcontractor

General Contractor's Information

Company Name

(ex. XYZ Custom Homes, LLC)

Mailing Address

(ex. 1234 Example Street)

Mailing Address Line 2

(ex. Suite 340)

City

State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Zip Code

Does the general contractor own the property?

YES

Help! I Don't Know - For your lien claim to be valid, the information in your Notice needs to be correct. You must find out if the general contractor or someone else owns the property. If you can not find out, we can assist you in a search of certain public records. If you want us to assist you, check this box . THIS WILL COST ONE CREDIT. Notice to Owner, L.L.C. will check the online county appraisal district records and the online official public records to assist you in identifying the owner of the property. Notice to Owner, L.L.C. CAN NOT guarantee the accuracy of these searches. Notice to Owner, L.L.C. disclaims any liability or loss by virtue of inaccurate or incorrect searches.

Owner's Information

Owner's Name/Company Name

Mailing Address

Mailing Address Line 2

City

State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Zip Code

Is this the owner's homestead?

YES

Company That Hired You

Company Name

Mailing Address

Mailing Address Line 2

City

State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Zip Code

Claimant's Information

Your Company's Name

Your Company's Street Address

Your Company's Street Address Line 2

Your Company's City

Your Company's State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Your Company's Zip Code

Amount owed to you that has not been paid:

$

Project Information

Project Street Address

Project Street Address Line 2

Project City

Project State

Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Project Zip Code

Did your provide (check one):

• Labor
• Materials
• Labor and Materials

Fill in the sentence: I performed or provided for the project.

(ex. Stone and tile, architecture services, trim carpentry services, graphic design services, exterior stone, granite countertops, punch services.)