Please prepare for our representative's signature a Notice of Performance and Non-Payment Lien in accordance with
the following information:
1) Date of first furnishing of materials or labor to jobsite:
2) Date of last furnishing of materials or labor to jobsite:
3) Our direct customer is:
4) The nature of the service, labor, and/or materials furnished by us at the jobsite was:
5) Total value of what we furnished (Note - Do Not include work Not done) $
6) Balance owed for what we furnished $ Retainage $
7) This was UNDER ONE CONTRACT or MULTIPLE CONTRACTS
8) Job name, address, legal description:
9) Notice to Owner was served as follows: or NTO#:
Served on: Check date mailed: or Received:
We hereby certify that the above described materials were used, or labor and services
were performed, in the improvement of the real property name above; that no waiver and
the above stated information is true and correct.
Our Firm name:
Email Address: *
Person to sign the NNP: President: VP:
Please print this completed screen using Control-P
When done, please or
* - required field FAX: 954.771.0925
NOTE - PLEASE DISCARD ANY PREVIOUS FAX NUMBERS.
THEY WILL NO LONGER WORK.
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