By Fax

QUESTIONNAIRE FOR FILING A MECHANIC’S LIEN – NYLIENS.COM
FILL OUT THIS FORM AND FAX IT TO NYLIENS.COM: 516-334-3000

OUR COMPANY INFORMATION:

1. Name of Our Company: _____________________________________
2. My Name: ___________________ Title: _________________
3. Check one: [ ] Individual, [ ] Sole Proprietorship, [ ] corporation, [ ] LLC – The State of Corp or LLC is [ ] NY – [ ] Other: ___________
4. Our Address: __________________________________________
5. City, State, Zip: _____________________________________________
6. Our email address: _________________________________________
7. Our phone number: ___________________8. Our fax number: __________

INFORMATION ABOUT OUR CUSTOMER:

9. Name of Company that we worked for or provided materials to: _____________
10. Their Address: __________________________________________
11. City, State, Zip: _____________________________________________
12. We worked for/our Contract was with (check one): [ ] The Owner, [ ] General Contractor, [ ] Subcontractor.
13. If we worked for a Subcontractor, the General Contractor was:______________
the Address of the General Contractor: ______________, (Zip) __________

INFORMATION ABOUT THE JOB:

14. The name of the job (if any name) was: _____________________________
15. The Address of the job is: ______________________________________
16. (City) ________, (County) ________, (State)_______ , (Zip) ___________
17. Enter the Block and Lot of the job (if known): BLOCK _______, LOT(S) ______

INFORMATION ABOUT THE PROPERTY TO BE LIENED:

18. The Owner of the Property (if known) is: _______________________________________
19. Owner’s Street Address is: _____________________________________
20. (City) ______________, (State)________________ , (Zip) ___________

INFORMATION ABOUT THE WORK PERFORMED OR MATERIALS FURNISHED:

21. The work that we performed on the job was (Describe): ______________________________________________________________________________________________________________
22. The materials sold or used on the job by us was :_____________________
23. The Total of the Contract or Invoiced work, including all legitimate extra work and change orders was:
$______________________
24. The amount now owed to us is (AMOUNT OF LIEN): $________________
25. The first date that we worked on or delivered materials to the project was: ______________,20___
26. The last date that we worked on or delivered materials to the project was: ______________,20___

IF THIS IS A PUBLIC IMPROVEMENT LIEN, PLEASE PROVIDE:

27. Name of the Agency: ________________________________________
28. Address of the Agency: ______________________________________
29. City, State, Zip Code: ________________________________________
30. The Contract Number is: _____________________________________


I/we request, hire and authorize NYLIENS LLC, Rosen Law LLC, its members and/or employees to act as my/our Agent to file a Notice of Mechanic’s Lien against the property indicated herein with the information that we have provided. We agree to hold harmless and indemnify NYLIENS LLC, Rosen Law LLC its members and its employees for any actions or proceedings brought against NYLIENS LLC, Rosen Law LLC its members and its employees as a result of the filing of the Mechanic’s Lien including for the willful exaggeration of a Notice of Mechanic’s Lien. The maximum liability of NYLIENS LLC, Rosen Law LLC its members and its employees for any and all reasons whatsoever, shall not exceed the actual funds paid by me/us for the filing of the Notice of Mechanic’s Lien. We understand that a Mechanic’s Lien must be filed within 120 days from the last date that we provided materials or labor to the job for single family homes and residential condominium units or eight (8) months from the last date that we provided materials or labor to the job for all other properties. NYLIENS LLC, Rosen Law LLC, its members and its employees do not guaranty that the Mechanic’s Lien will be timely filed unless we are in receipt of this form, properly completed at least 30 days prior to the expiration of the applicable time period. We agree to pay NYLIENS LLC the sum of $400.00 ($500 for Nassau and Suffolk Counties [“Fee”]). The fee includes the preparation of the mechanic’s lien, the filing of the Mechanic’s Lien with the County Clerk in the County where the property is located and the sending by Certified Mail of one Notice of Mechanic’s Lien to the Owner of the property provided that I/we provide the proper name and address of the Owner. If we do not have the Owner’s name and NYLIENS LLC obtains the name of the Owner and it is not correct, we will not hold NYLIENS LLC, Rosen Law LLC or its members and/or employees liable for the failure to locate the correct name of the Owner. I/we represent that if a license if or was required to perform the work, labor and services that I/we performed that we held the required licenses. NYLIENS LLC includes with this filing service, sending one notice to the owner. Notices to the general contractor will be included for an additional $50.00 (include this information in the space provided below).

[SIGN HERE TO AUTHORIZE]____________________________________

PAYMENT INFORMATION (CHECK ONE):

[ ] PAYMENT BY CREDIT CARD
CARD TYPE (check one): [ ] VISA, [ ] MASTER CARD, [ ] AMERICAN EXPRESS
CARD NUMBER _____________________________________________
EXPIRATION DATE (month/year): ________
CID# on card (3 or 4 digit printed number): ________
NAME ON CARD: ___________________________________________
PRINT NAME: ________________________________ DATE: ________
BILLING ADDRESS: _________________________________________
CITY: ______________________ STATE: ______ ZIP CODE: __________

[SIGN HERE]______________________________________________

I HAVE READ THE ABOVE AND I AGREE TO THE TERMS AND CONDITIONS SET FORTH ABOVE AND I/WE AUTHORIZE NYLIENS LLC AND/OR ITS AFFILIATES INCLUDING ROSEN LAW LLC TO CHARGE MY/OUR CREDIT CARD THE AMOUNT OF $400.00 (THE “FEE”) PLUS AN ADDITIONAL FEE OF $50.00 FOR GENERAL CONTRACTORS TO FILE A MECHANIC’S LIEN AND TO KEEP THE CREDIT CARD NUMBER ON FILE FOR FUTURE LIEN FILINGS. NYLIENS LLC WILL NOT FILE THE NOTICE OF MECHANIC’S LIEN UNTIL RECEIPT OF PAYMENT BY NYLIENS LLC. IN THE EVENT THAT NYLIENS LLC PREPARES A NOTICE OF MECHANIC’S LIEN AND SENDS IT TO ME/US [THE APPLICANT(S)] FOR SIGNATURE, AND I/WE DECIDE NOT TO HAVE THE NOTICE OF MECHANIC’S LIEN FILED, THEN I/WE AGREE TO PAY $400.00 (THE “FEE”) PLUS THE $50.00 TO SERVE THE GENERAL CONTRACTORS TO NYLIENS LLC FOR THE PREPARATION OF THE NOTICE OF MECHANIC’S LIEN. There will be a 3% convenience fee for payments made by credit card.

[ ] PAYMENT BY CHECK:
Mail $400.00 ($500.00 in Nassau and Suffolk Counties) (the “fee”) plus $50.00 for General Contractors to: NYLIENS LLC, 216 Lakeville Road, Great Neck, NY 11020.
[ ] Add $499.00 RUSH SERVICE fee:
PRINT NAME: ________________________________ DATE: ________

[SIGN HERE]______________________________________________

NYLIENS LLC will not file the Notice of Mechanic’s Lien until receipt of the payment by NYLIENS LLC.