LIEN & BOND PROTECTION FORM Please proceed with (check one or more of the following): Is account past due? Date Project Location (State) # PAGES FAXED A. CLAIMANT INFORMATION: Address: 1. Your company's exact corporate Name: City: State: Zip: 2. Tel: Fax: State of incorporation: 3. Your Customer's Name: Your Reference No.: (Complete address & telephone number on appropriate line below under "Project Information.") B. MATERIAL OR LABOR INFORMATION: 1. Did you furnish: 2. Date of P.O./Contract: 3. Brief Description of what your company furnishes: 4. Actual and/or estimated dates materials/labor has or will be furnished (for TX, provide statement of account.) First: Last: Ongoing? 5. Total Amt of Invoices $: Total Amt. Paid $: Total Balance $: C. PROJECT INFORMATION: (Please check all that apply) 1. Project (jobsite) Name: Address: 2. Project Owner/Lessee: Tel: Address: 3. Gen. Contr./Const. Mgr.: Tel: Address: 4. Subcontractor: Tel: Address: 5. Sub-subcontractor: Tel: Address: 6. Construction Lender: Tel: Address: 7. Bonding Co./Agent: Tel: Address: Bond No.: Project No.: D. MISCELLANEOUS: 1. Please attach any of the following if available to you:
2. The undersigned authorizes the filing of a Lien or Claim on behalf of the said claimant. It is the responsibility of the undersigned to ensure accuracy of information and sufficient time allowance for filing. LienMaster or local counsel are not responsible for any inaccurate information provided, lack of information, or insufficient time allowance for filing. Submitted by: E-mail:   (Will be used to send you an E-mail confirmation only) Print name and title: Date:   Attach files to this form
PLEASE CLICK ON THE "SUBMIT THIS FORM" BUTTON ABOVE, OR FAX OR EMAIL THIS FORM TO INITIATE ACTION
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