MECHANICS LIEN CLAIM

(Connecticut)

I. DOCUMENT HEADER

1. Claimant: [CLAIMANT LEGAL NAME], [ENTITY TYPE], License No. [LICENSE] (if applicable).
2. Claimant Address: [ADDRESS].
3. Property Owner: [OWNER NAME].
4. Owner Address: [OWNER ADDRESS].
5. Hiring Party (if not Owner): [HIRING PARTY NAME AND ADDRESS].
6. Project Name: [PROJECT NAME].
7. Property Address: [STREET ADDRESS, CITY, CT ZIP].
8. Legal Description: [LEGAL DESCRIPTION] (attach Exhibit A if needed).
9. Town/County: [TOWN/COUNTY], Connecticut.
10. Lien Amount: $[AMOUNT].
11. First Furnishing Date: [DATE].
12. Last Furnishing Date: [DATE].

II. CERTIFICATE OF MECHANICS LIEN

Claimant certifies that it furnished labor, services, equipment, and/or materials for the improvement of the Property described above. The amount due and unpaid is $[AMOUNT], after all just credits and offsets.

III. DESCRIPTION OF WORK

General description of labor/materials:

• [DESCRIPTION OF WORK OR MATERIALS]
• [DESCRIPTION OF WORK OR MATERIALS]

IV. BASIS FOR LIEN

☐ Contract with Owner
☐ Contract with Direct Contractor
☐ Contract with Subcontractor
☐ Other: [OTHER]

V. NOTICE AND DEADLINES

• Notice of intent served (if required): ☐ Yes ☐ No
• Date notice served: [DATE]
• Method of service: ☐ Certified mail ☐ Personal delivery ☐ Other: [METHOD]
• Certificate recorded on: [DATE]

VI. VERIFICATION

I, [NAME], am [TITLE] of Claimant and have personal knowledge of the facts stated herein. I declare under penalty of perjury that the foregoing is true and correct.

Signature: ________________________________

Printed Name: [NAME]

Date: [DATE]

VII. NOTARY ACKNOWLEDGMENT

State of Connecticut )
County of [COUNTY] )

Subscribed and sworn before me on this ___ day of ____________, 20__, by [NAME].

Notary Public: ________________________________

My Commission Expires: _________________________