Your Company Name
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Mailing Address
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City
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State
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Your Name
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Title
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Phone
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Email
Date Sent
CUSTOMER INFORMATION
Name of your Customer (who owes you money)
*
Name of the Owner
Name of the General
PROPERTY INFORMATION
Property Street Address (Job Site)
*
Parcel # (from SCR Filing)
Lot/Subdivision (if available)
Legal Description (if known)
LIEN INFORMATION
SCR Entry Number
First Date of Work/Delivery of Materials (when did you start)
*
Last Date of Work/delivery of Materials (when did you finish your part)
*
Description of Material/Labor Provided
*
Exact amount due (Principal amount only)
*
Lien Fee Amount (include at least $200.00 for lien and release fees)
90th Day or 180th Day (last day to lien)
Lien by: (ie ASAP or the date you want it liened by)
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