Part I - Request
1. To: ( lien service) Assurance Lien Services, LLC. Attn: Kelly SilvesterP. O. Box 160083Clearfield, Utah 84016kelly@lienservice.com(801) 520-4500
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 Select State UT 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 AA AE AP AS FM GU MH MP PR PW VI 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 $300.00* 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)
Comments