File a Lien - Speedy Lien, Inc.

File a Speedy Lien

Servicing New York, New Jersey, Connecticut and Pennsylvania

File a Mechanic's Lien with Speedy Lien

We request Speedy Lien, Inc. to prepare, sign and file a Mechanic’s Lien on our behalf as our agent. The information we provided is true and correct and we assume responsibility in the event information provided is incorrect. The filing fee is $475.00 (** with the exception of jobsites located in Nassau County/ Suffolk County/ State of Connecticut – the filing fee is $575.00 **).

YOUR CONTACT INFORMATION

1 - Our Company's Exact Name *

2 - We Are Incorporated: *

Yes

3 - Address *

3a - City *

3b - State *

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 Your Office *

(If we have any questions, who should we speak with?)

6a - Contact's Email Address *

JOBSITE INFORMATION

7 - Address of Jobsite *

7a - City *

7b -State *

7c - Floor/Suite #

7d - Store or Tenant's Name

8 - Labor Performed *

(What type of work was performed?)

9 - Materials We Used/Sold

(Did you supply materials?)

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

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

11 - Grand Total of Contract (Work Completed) or Sale (Include Extras and Taxes) *

(Grand total of services rendered to date)

11a - The Exact Amount We Are Owed *

(Including retainage)

12 - Direct Customer/Client that Hired Us: *

(Who hired you?)

12a - Their Address: *

12b - City *

12c - State *

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

(If you were contracted directly by the General Contractor, please list their info for #12, direct party whom hired you.)

13b - General Contractor's Address:

13c - City

13d - State 13d - State

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/Municipality

14b - Contract #

I/We agree to pay Speedy Lien, Inc. $475.00 (or $575.00 for jobsites located in Nassau County, Suffolk County or the 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

Exp Year

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

Yes

Paying By Check:

Check Payable to: Speedy Lien, Inc.

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

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File a Speedy Lien

Servicing New York, New Jersey, Connecticut and Pennsylvania

File a Mechanic's Lien with Speedy Lien

YOUR CONTACT INFORMATION

JOBSITE INFORMATION

PAYMENT INSTRUCTIONS

Paying By Check:

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We Service

Your Lien is Filed

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Contacts

Where we File

What we File