OUR (the applicant) COMPANY INFORMATION:
Our Company Name:
Reqistered State For Corporation or LLC:
City / State / Zip:
INFORMATION ABOUT OUR CUSTOMER:
Name of Company we worked for or provided materials to:
Their City / State / Zip:
We worked for/our Contract was with (check one):
If the work was done for a Subcontractor, list the General Contractor Info below.
General Contractor Name:
General Contractor Address:
GC City / State / Zip:
INFORMATION ABOUT THE JOB:
Job Name (if any):
Job City / State / Zip:
Job Block / Lot(s) (if known):
INFORMATION ABOUT THE PROPERTY TO BE LIENED:
Property Owner (if known):
Owner City / State / Zip:
INFORMATION ABOUT THE WORK PERFORMED OR MATERIALS FURNISHED:
Describe the work performed:
Describe the materials used:
Total of the Contract or Invoiced work, including all legitimate extra work and change orders:
Total now owed (Amount Of Lien):
The first date that we worked on or delivered materials to the project was:
The last date that we worked on or delivered materials to the project was:
IF THIS IS A PUBLIC IMPROVEMENT LIEN, PLEASE PROVIDE:
Name of the Agency:
Agency City / State / Zip:
Agency Contact Number:
I/we request, hire and authorize NYLIENS LLC, Gary Rosen Law Firm, PC, 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, Gary Rosen Law Firm, PC its members and its employees for any actions or proceedings brought against NYLIENS LLC, Gary Rosen Law Firm, PC 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, Gary Rosen Law Firm, PC 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, Gary Rosen Law Firm, PC, 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 ($500.00 for Nassau and Suffolk Counties) (the "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, Gary Rosen Law Firm, PC 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. Additional notices to the general contractors will be included for $50.00 (include this information in the space provided below).
Retype Name and Comany to Accept the Terms Above:
Send notice to general contractors ($50.00 per notice). Include all contact information available for each added notice:
CREDIT CARD PAYMENT INFORMATION:
Credit Card Type:
Credit Card Number:
Credit Card Exp. Date:
Name On Card:
City, State, Zip:
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 GARY ROSEN LAW FIRM PA TO CHARGE MY/OUR CREDIT CARD THE AMOUNT OF $400.00 ($500.00 for Nassau and Suffolk Counties) (plus $50.00 for General Contractors notice) 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 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.
Retype Name and Date to authorize Credit Card charge:
(check one): How did you hear about NYLIENS?
email from NYLIENS
received advertisement from NYLIENS (postcard, etc.)
referred to NYLIENS from a friend or colleague
we've used NYLIENS before
To the best of my knowledge all information above is accurate and I agree that NYLienc LLC and/or Gary Rosen Law Firm PC are not responsible or liable to me for renewal or failure to renew any lien that I request to be filed by them.
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Then, click on the SUBMIT button once.