Speedy Lien, Inc.

INSTRUCTIONS

Step 1

COMPLETE THE FOLLOWING WORKSHEET:

Speedy Lien, Inc.
"The Mechanic's Lien Clearing House" ™
200 Old Country Road - Suite 310
Mineola, NY 11501
Tel: 516-679-6702
Fax: 516-679-6703

WE REQUEST THAT SPEEDY LIEN INC. FILE A MECHANIC’S LIEN AGAINST THE FOLLOWING PROPERTY REPRESENTING US AS OUR AGENT. THE INFORMATION WE PROVIDED IS TRUE AND CORRECT. WE ASSUME RESPONSIBILITY IN THE EVENT THE INFORMATION PROVIDED IS INCORRECT.

1.	Our Company's Exact Name:
2.	Corporation?	YesNo
3.	Company Address:
	City / State / Zip:
4.	Phone / Cell / Fax:
5.	Officer's Name/ Title:
6.	Office Contact Name / Email:
7.	Address of Jobsite to be Liened:
	City / State / Zip:
7a.	Store / Tenant / Floor# / Apt#:
8.	Materials Sold / Used / Rented:
9.	Labor Performed:
10.	First Date at Jobsite (MM/DD/YYYY):	/ /
11.	Last Date at Jobsite (MM/DD/YYYY):	/ /
12.	Grand Total of Contract/Invoiced to Jobsite Including All Change Orders:	$ .
13.	Exact Amount We Are Owed:	$ .
14.	The Party That Hired Our Company:
15.	Their Address:
	City / State / Zip:
16.	General Contractors Name: If Different than #14. (Additional $25 Filing Fee)
	Contractor Address:
	City / State / Zip:
17.	Name of Property Owner / Block / Lot#: (If Known)
18.	Agency/Municipality Contract Number: (If Public Improvement or Municipal Lien)
19.	Do you want the original court stamped Mechanic's Lien sent by United Parcel Service?	Yes ($15 fee)No
20.	If we locate property owner's Attorney, do you want them served?	Yes ($25 fee)No

I/We agree to pay Speedy Lien Inc. $295.00 for New York Liens, $325.00 New Jersey Commercial Properties, $500.00 New Jersey Municipal Liens. Contractors state they are licensed in the county where the labor was performed. For New Jersey Properties only, lienor states I/We have a signed contract and/or signed delivery receipts. I/We are aware that Speedy Lien Inc. is liable only to the extent of the cost of the Mechanic's Lien. I/We are aware that the Information contained in this form is the proprietary right of Speedy Lien Inc. and may not be reproduced without their expressed written consent or sent to anyone other than Speedy Lien Inc, I/We are aware that any unauthorized use of this form is a violation of law and can be prosecuted to the fullest extent of law.

21.

Signature / Date:
(Type your name as signature)

Step 2

CHOOSE PAYMENT OPTION:

If paying by credit card complete the following:

My/Our credit card is already on file.

Cardholder's Name:
Billing Address:
City:
State:
Zip:
Card Type:
Card Number:
Card Expiration Date:	/
	I/We authorize Speedy Lien Inc. to charge my/our credit card and to keep this credit card on file for our future needs.

If paying by check, make your check payable to: Speedy Lien Inc.

200 Old Country Road – Suite 310
Mineola, New York 11501

Step 3

TO EXPEDITE THE FILING OF YOUR MECHANIC’S LIEN:

Electronic Mail: (only if paying by credit card)

• Select the "I Agree" option below and click "Submit".

I AGREE

Fax:

• Print Worksheet and Credit Card Information sheet and then fax to us at 516-679-6703

Mail:

•  Print Worksheet and mail to us with a check in the amount of:
   $295.00 New York State Mechanic's Liens
   $325.00 New Jersey Commercial Mechanic’s Liens
   $500.00 New Jersey Municipal/Public Improvement Liens

Step 4

Please call us at 516-679-6702 to confirm our receipt of your Mechanic’s Lien request.

"Thank you for thinking of Speedy Lien. We appreciate your business".

Mark Nash “Your Lien King” and
The Staff of Speedy Lien Inc.