Notice of Furnishing

Is the client a business REGISTERED with a secretary of state? YesNo

Registered with which STATE?

Client's Name?

If not a registered business, are you doing business under a FICTITIOUS NAME?YesNo

What is the FICTITIOUS NAME?

What TYPE of Business?

Client Address - Line 1

Client Address - Line 2

Client's Email Address?

Who is signing the affidavit for client?

CONTRACTING PARTY: To whom did you provide materials or for whom did you perform labor?

ADDRESS of contracting party?

DATE on which labor/materials were performed/furnished or will be performed/furnished?

ORIG. CONTRACTOR: NAME of Original Contractor from Notice of Commencement?

Original Contractor ADDRESS - Line 1

Original Contractor ADDRESS - Line 2

OWNER: Owner, part-owner, lessee, or designee from Notice of Commencement?

Owner ADDRESS - Line 1

Owner ADDRESS - Line 2

STATE where work performed?

COUNTY where work performed?

Property Address?

Permanent Parcel Number?

Additional Comments

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