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CONSTRUCTION LIEN REQUEST


To request a lien, complete the fillable form below and submit

Lien Request Form2

Part I - Request

1. To: ( lien service)

Assurance Lien Services, LLC.

Attn: Kelly Silvester

P. O. Box 160083

Clearfield, Utah 84016

kelly@lienservice.com

(801) 520-4500

2. From: (your company name)*



Mailing Address *

City *

State

Zip Code


Phone*

3. Your name: *

Email*

4. Title:

5. Date Sent:

6. Name & Address of your customer: (who owes you money)*

7. Name of the Owner

8. Name of General(if known)

Part II – Property Information

9. 9. Property Street Address (Job Site) *

10. County


11. SCR Filing #

12. Parcel # (from SCR filing )

13. Lot/Subdivision: (if available)

14. Legal Description (if known):

Part III – Lien Information

15. First Day of Delivery of Materials/Work (when did you start)*

16. Last Day of Delivery of Materials/Work: (when did you finish your part)*

17. Exact amount due (Principal amount only) *

18. Lien Fee Amount (Include at least $250.00* for lien & release)

$

19. * Description of Material/Labor Provided *


20. 90th day or 180 th : (last day to lien)

21. Lien by: (ie ASAP or when you want it by)


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