Lien or Bond Claimant Information (Who Are You?)
Your Name
  
Email Address
  
Your Company’s Exact Corporate Name
Address

Telephone Number
State of Incorporation
Your Status in the Project
 Subcontractor
 Material Supplier
General Contractor
Do You Have a Written Contract?
 No Yes
Do You Have a Notice of Commencement and/or Payment Bond?  (If yes, please fax a copy to
(248) 851-1094, Attn: Ronald B. Rich,
or email it to info@letuscollect.com)
No Yes
Entity With Whom You Contracted (enter details below)
Contract Amount (including extras)
Payments Received
Amount Currently Due on the Contract
Material and Labor Information - Did You Provide:
 Both Labor and Materials
 Labor only
Materials only
Description of Materials and/or Services Provided: 
First date of providing labor or materials to the job:
Last date of providing labor or materials to the job:
Project Information - Job Site Name:
Address:

Legal description of property: See attached legal description.

Owner:

Address:

Phone:
General Contractor:
Address:
Phone:
Bonding Company:
Address:
Phone:
Subcontractor (if applicable):
Address:
Phone:

Please Provide Me (What Do You Want?)

Notice of Furnishing              Bond Notice
 Lien                                   Bond Claim
Lien Discharge                     Other        
Before submitting the form, please review and verify all information is correct.  Ronald B. Rich & Associates is not liable for misinformation.