CLAIM OF LIEN – NOTICE OF NONPAYMENT WORKSHEET FORM (Basic Information for Processing a Claim of Lien/Notice of Nonpayment) MID STATE NOTIFIER19 NW 8 ST, OCALA, FL 34475INFO@MIDSTATENOTIFIER.COM 352-861-9100 NOTE: Due to the high volume of storage, we will maintain and store records in our warehouse for a period of 2 years. If you have any need for the Notice to Owners, Proof of Service or Claim of Liens, it is your responsibility to notify us and obtain these records to avoid being destroyed. TODAYS' DATE NTO DATE PROJECT NAMEPROJECT ADDRESS, CITY ZIPPROJECT COUNTYLEGAL DESCRIPTIONDESCRIPTION OF WORKOWNER'S NAME & ADDRESSDATE OWNER RECEIVED CERTIFIED (Information provided by Mid State Notifier if we did the NTO)FIRST DATE ON THE JOB LAST DATE ON THE JOB CONTRACT AMOUNTAMOUNT OWINGRETAINAGEHOW MUCH HAVE YOU BEEN PAIDYOUR INFORMATIONCOMPANY NAMECONTACT NAMEADDRESS STREET ADDRESS CITY STATE/PROVINCE ZIP/POSTAL CODE REPRESENTATIVE THAT WILL HAVE THEIR NAME SIGNED/NOTARIZED ON RELEASE(IT IS NOT NECESSARY TO NOTARIZE THIS FORM) PHONEFAXEMAIL* FILE Drop files here or CaptchaVerify that you are a real human.
