Do you have a contract directly with the owner of the property? —Please choose an option—YesNo Do you have a copy of the original contract? —Please choose an option—YesNo If so, is it signed by both husband and wife? —Please choose an option—YesNo Were the materials you furnished specially fabricated? —Please choose an option—YesNo During what months did you furnish materials or labor for which you have not been paid? —Please choose an option—YesNo Your name Your Title Your address Address of property Legal description of property Name of the General Contractor Address of the General Contractor Name of the Owner Address of the Owner Description of the labor and materials provided Amount Due for each month you supplied labor and/or materials: ex. March 21 $3,972, April 21 $1,649 Does the amount due include retainage? —Please choose an option—YesNo If so, how much? Have you sent a Notice of Claim? —Please choose an option—YesNo If so, Date Notice of Claim sent County where property is located
