At the beginning of the form, the claimant will need to print their full name. They must also print the county in which the work was completed, along with the full address of the property that they completed the work at.
In the second clause, the claimant must write the amount that the property owner still owes them. This should exclude any offsets and just credits. They’ll also have a blank to fill in the interest rate, along with the date that the balance was originally due. They’ll need to provide a description of the type of equipment, services, materials, or labor that they furnished for the project.
In the third part, the claimant should provide the name of the employer or entity that their equipment, services, materials, or labor was furnished to. The fourth part will capture the address and name of the property owner. Finally, the claimant should write their own address in the fifth part.
They will then need to provide the date that the form was filled out, along with their signature.
If another authorized party is completing the lien, they will need to provide their name under the “Verification” portion, as well as their relationship to the claimant. They will also need to give a date of the verification and a signature.