FILE A LIEN

Speedy Lien, Inc.
“The Mechanic’s Lien Clearing House” ™
170 Old Country Road
Mineola, New York 11501
516-679-6702 / 212-203-7420 / 732-945-8262

We request Speedy Lien, Inc. prepare a Mechanic’s Lien on our behalf. The information we provided is true and correct and we assume responsibilty in the event information provided is incorrect.

Printable Form

YOUR CONTACT INFORMATION

1 - Our Company's Exact Name *

2 - We Are Incorporated: *

Yes

No

3 - Address *

3a - City *

3b - State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

3c- Zip *

3d - Floor/Suite #

4 - Phone *

Extension

5 -   Officer's Name *

5a - Officer's Title *

5b - Officer's Email Address *

5c - Cell Number *

6 - Contact Name in Our Office *

6a - Contact's Email Address *

JOBSITE INFORMATION

7 - Address of Jobsite *

7a - City *

7b-State * NY NJ CT PA

7c - Floor/Suite #

7d - Store or Tenant's Name

8 - Materials We Used/Sold *

9 - Labor Performed

10 - Exact First Date at Jobsite (Line #7) *

10a - Exact Last Date at Jobsite (Line #7) *

11 - Grand Total of Contract/Sale (Include All Extras/Change Orders/Taxes) *

11a - The Exact Amount We Are Owed *

12 - Direct Customer/Client that Hired Us: *

12a - Their Address: *

12b - City *

12c -State * AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

12d - Zip *

12e - Floor/Suite #

12f - Phone *

Extension

12g - Contact Name *

12h - Email Address

13 - General Contractor (If Different From Line #12 - The Company That Hired Line #12)
                          **There is a $50 Fee to Serve the General Contractor**

13a - General Contractor's Name

13b - General Contractor's Address:

13c - City

13d - State AK AL AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other

13e - Zip

13f - Floor/Suite #

13g - Phone

Extension

13h - Contact Name

13i - Email Address

14. Public Improvement - If a Public Improvement / Municipal Project (provide agency & contract #)

14a - Agency/Municipility

14b - Contract #

15. Do you want docketed Mechanic's Lien sent to you by UPS? * Yes - $15 No - $0

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I/We agree to pay Speedy Lien, Inc. $400 ($500 for Nassau / Suffolk Counties / State of Connecticut) for their services and agree that services commence upon their receipt of this document. I/We are aware that Speedy Lien, Inc. is liable to the extent of the cost of the Mechanic’s Lien in the event of error. I/We are aware that the information contained in this document is the proprietary right of Speedy Lien, Inc. and will not be sent to any other entity other than Speedy Lien, Inc. I/We are aware than any unauthorized use of this document is a violation of law and Speedy Lien, Inc. will prosecute to the fullest extent of the law.

Type Your Name as Signature *

Date *

PAYMENT INSTRUCTIONS

Paying by Credit or Debit Card, Complete the Following:

Use Credit Card on File

Yes

Cardholder's Name

Billing Address

Zip Code

Card Number

Exp Month 1 2 3 4 5 6 7 8 9 10 11 12

Exp Year 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

***Please Note: If Paying by Credit or Debit Card, There is a 3% Convenience Fee***

I/We authorize Speedy Lien, Inc. to charge my/our credit card. *

Yes

Check Payable to:
Speedy Lien, Inc.

Print Intake Sheet, Prepare Check and Email Z@SpeedyLienInc.com
OR
Print Intake Sheet, Prepare Check and Fax: 516-679-6703

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“There is Never a Valid Time to Wait.”
Mark Nash, The Lien King ™
Flattery: Being mentioned in a competitors website.

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