National Lien & Bond Claim Systems

A division of Network 50, Inc.

CLAIM DATA SHEET

First name

Last name

State/Region

Zip Code

1. SELECT TYPE OF FILING OR CLAIM

2. YOUR CONTRACT INFORMATION

Customer's Company Name

Customer First Name

Customer Last Name

Customer Street Name

Customer City

Customer State

Customer Zip

Customer Phone

Customer Email

Contract Date

Year/Month/Day

Customer Account #

Job Number

P.O. / Contract Number

Contract Base Amount

Is Your Contract Written or Verbal?

Does All Extra Work Relate to Original Contract?

Attach Contract Copy

Attach all other project related documentation

3. DESCRIPTION OF YOUR PRODUCT/ SERVICES PROVIDED

Add Description Here

Is Your Product Custom Manufactured for the Project?

4. CONSTRUCTION TYPE

5. DATES OF WORK/FURNISHING/SHIPPING

First Date of Work/Furnishing/Shipping

Year/Month/Day

Last Date of Work/Furnishing/Shipping

Year/Month/Day

Is The Project As A Whole Completed?

Project Certificate/Notice of Completion or Acceptance

8. YOUR STATUS IN PROJECT

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National Lien & Bond

PROJECT DATA SHEET

Project Contact First Name

Project Contact Last Name

Project Street Address

County of Project

Project City

Project Zip code

Project Phone

Project Email

2. PROJECT OWNER / PUBLIC AGENCY

Owner First Name

Owner Last Name

Owner Street Address

Owner City

Owner State

Owner Zip Code

Owner Phone

Owner Email

3. ORIGINAL CONTRACTOR

Contractor Company Name

Contractor First Name

Contractor Last Name

Contractor Street Address

Contractor City

Contractor State

Contractor Zip Code

Contractor Phone

Contractor Email

Subcontractor Company Name

Check Here if:

If you have already provided details, no need to fill them again here.

Subcontractor is the Customer

Subcontractor First Name

Subcontractor Last Name

Subcontractor Street Address

Subcontractor City

Subcontractor State

Subcontractor Zip Code

Subcontractor Phone Number

Subcontractor email

5. Project Notices

Has the GC or owner filed a notice that the project has commenced?

Please attach copy of notice

Is There a Payment Bond?

Payment Bond #

Name of Bonding Company

Bond Contact Name

7. Misc. Project Information

List other people involved in Project – Architects, Engineers, Title Co., Lenders and any others:

8. CREDIT INFORMATION

Joint Check

Direct Payment

Have You Issued A Preliminary Notice?

Attach Copy of Preliminary Notice

Have You Issued A Lien Waiver?

Attach Copy of Lien Waiver

9. YOUR DOCUMENT CHECKLIST

NLB will not open a file until you receive a copy formation and approve the filing.

Please call 1-800-432-7799 to verify that your claim form was received.

You may request customer service by clicking here or schedule a call by clicking here.

Email: info@mechanicslien.com

A division of Network 50, Inc.

CLAIM DATA SHEET

YOUR INFORMATION

1. SELECT TYPE OF FILING OR CLAIM

2. YOUR CONTRACT INFORMATION

3. DESCRIPTION OF YOUR PRODUCT/ SERVICES PROVIDED

4. CONSTRUCTION TYPE

5. DATES OF WORK/FURNISHING/SHIPPING

6. PROJECT STATE

7. PROJECT TYPE

8. YOUR STATUS IN PROJECT

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National Lien & Bond

PROJECT DATA SHEET

1. PROJECT

2. PROJECT OWNER / PUBLIC AGENCY

3. ORIGINAL CONTRACTOR

4. SUBCONTRACTOR

5. Project Notices

6. ALL JOBS

7. Misc. Project Information

8. CREDIT INFORMATION

9. YOUR DOCUMENT CHECKLIST

10. MISCELLANEOUS