Unpaid Balance Notice Request The Notice of Unpaid Balance is used in several states as a prerequisite for claiming a Lien. This Notice informs the necessary parties of the unpaid balance due you for the labor, materials, equipment or services provided to the referenced Construction Project, and positions you to file a Claim of Lien should your job related accounts receivable remain unpaid after these notices have been properly served. Unpaid Balance*Please select the appropriate requestAlabama-Notice of Non PaymentArizona-Notice of Non PaymentCalifornia-Notice of Non PaymentFlorida-Notice of Non PaymentLouisiana-Notice of Non PaymentNew Jersey-Notice on Non PaymentNorth Carolina-Notice of Non PaymentOhio-Notice of Non PaymentTennesse-Notice of Non PaymentTexas-Notice of Unpaid Balance - 1st RequestTexas-Notice of Unpaid Balance - 2nd RequestTexas-Notice of Unpaid Balance - Final RequestUtah-Notice of Unpaid BalanceVirginia-Notice of Non PaymentWisconsin-Notice of Non PaymentFunds Trapping or Unpaid Balance RequestDate Requested* Company InformationThe following is my company information:My First Name*My Company: My First NameMy Last Name*My Company: My Last NameMy Email* My Company: Contact eMailCompany Name*My Company: NameAddress Line 1My Company: Street AddressAddress Line 2My Company: PO Box, Suite #Address Line 3My Company: Building Reference, Floor, Attn:CityMy Company: CityStateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYMy Company:Please Select StateZipMy Company: ZIPMain PhoneMy Company: Main Phone NumberCell PhoneMy Company: Cell Phone NumberFaxMy Company: Main FAX NumberProject InformationThe following is the project information for the Real Property being improved or to be improved and referenced in this Notice:Job Site*Job Site Name / Project IdentificationJob Reference No.*Your identification for this projectEstimated Amount*Your dollars value estimate which may include adds, moves, and changesAddress Line 1*Jobsite: Street AddressAddress Line 2Jobsite: PO Box, Suite #Address Line 3Jobsite: Building Reference, Floor, Attn:City*Jobsite: CityState*ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYJob site:Please Select StateZipJobsite: ZIPPhoneJobsite: PhoneStart Date* Date you will START to supply materials, labor, or services to this project.End Date Date or Estimate Date, you will STOP supplying materials, labor or services to this projectDescription*A brief, but comprehensive, description of the materials, labor, or services you will provide to this projectCustomer InformationThe following is my customer information (if the general contractor and your customer are one in the same, enter "Same as General Contractor" and enter your customer information in the General Contractor fields- This information is required)My Customer's Name*Contact First Name*My Customer: Contact First NameContact Last Name*My Customer: Contact Last NameEmail My Customer's: eMail AddressAddress Line 1*My Customer's: Street AddressAddress Line 2My Customer's: PO Box, Suite #Address Line 3My Customer's: Building Reference, Floor, Attn:City*My Customer's: CityState*ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYMy Customer's: StateZip*My Customer's: ZIPMain Phone*My Customer's: Main Phone NumberCell PhoneMy Customer's: Cell Phone NumberFaxMy Customer's: FAXGeneral Contractor InformationThe following is the General Contractor information (if the general contractor and your customer are one in the same, enter all information in the General Contract section.)Company NameName of the Direct / General Contractor for this ProjectContact First NameGeneral Contractor: Contact First NameContact Last NameGeneral Contractor: Contact Last NameEmail General or Direct Contractor: eMailAddress Line 1General or Direct Contractor: Street AddressAddress Line 2General or Direct Contractor: PO Box, Suite #Address Line 3General or Direct Contractor: Building, Floor, Attn:CityGeneral / Direct Contractor: CityStateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYGeneral / Direct Contractor:Please Select StateZIPGeneral or Direct Contractor: ZIPMain PhoneGeneral or Direct Contractor: Main PhoneCell PhoneGeneral or Direct Contractor: Cell PhoneFaxGeneral or Direct Contractor: FAXProperty Owner InformationThe following is the Property Owner information (This information will be researched by CRM. If Known, please complete the following information about the Property Owner- This information is required for a Preliminary Notice.)Owner NameProperty Owner: Company NameContact First NameProperty Owner: Contact First NameContact Last NameProperty Owner: Contact Last NameEmail Property Owner:eMailAddress Line 1Property Owner: Street AddressAddress Line 2Property Owner: PO Box, Suite #Address Line 3Property Owner: Building Reference, Floor, Attn:CityProperty Owner: CityStateALAKAZARCACOCTCTDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYProperty Owner: StateZIPProperty Owner: ZIPMain PhoneProperty Owner: Main PhoneCell PhoneProperty Owner: Cell PhoneFaxProperty Owner: FAXJob CategorySelect Job CategoryPrivatePublicFederalOtherUnknownPlease choose the appropriate JOB CATEGORYJob ClassificationSelect Job ClassResidentialNon-ResidentialCommercialIndustrialTribal LandOtherUnknownPlease choose the appropriate JOB CLASSIFICATIONRTOSelect your RTODirect1st Tier2nd Tier3rd Tier4th Tier or moreOtherUnknownPlease indicate your POSITIONING on this projectConstruction Lender or Bonding Company InformationThe following is the Construction Project Lender / Bonding Company information (This information will be researched by CRM. If Known, please complete the following information about the Project Financing.)Company NameLender: Company NameContact First NameLender: Contact First NameContact Last NameLender: Contact Last NameLoan/Bond NumberConstruction Loan and/or Payment Bond InformationAddress Line 1Lender: Street AddressAddress Line 2Lender: PO Box, Suite #Address Line 3Lender: Building Reference, Floor, Attn:CityLender: CityStateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYLender:Please Select StateZipLender: ZIPMain PhoneLender: Main PhoneCell PhoneLender: Cell PhoneFaxLender: FAXPlease include; Special Instructions, Additional Entities to be Served, or other information which you are unable to enter in other sections of this form.To capture any additional information needed for the processing of this request.Required Information (Balance Due Support)The following information is mandatory to process a Notice of Unpaid Balances:Contract / PO $Contract or Purchase Order Dollar AmountStart Date Date you FIRST supplied Materials, Labor, or ServicesStop Date Date you expect to FINISH supplying services/labor/materials to the project:List Your UNPAID Invoice informationPlease list: Number, Date, and Amount of all unpaid invoices1st Invoice #1st Invoice Number1st Invoice Date 1st Invoice Date1st Invoice $1st Invoice Total2nd Invoice #2nd Invoice Number2nd Invoice Date Second Invoice Date2nd Invoice $Second Invoice Total3rd Invoice #Third Invoice Number3rd Invoice Date Second Invoice Date3rd Invoice $Third Invoice TotalTotal Unpaid BalanceTotal of all Unpaid InvoicesDate Balance Due: Date Balance Became DuePlease select your payment method below.Payment Method*CRM AccountCredit CardPlease include your 5 digit account number when selecting CRM Account as your payment method. Thank You.Attention: CRM Open Account CustomersPlease enter your 5 digit CRM Account number or choose the Credit Card/Paypal Option. New clients may apply for a CRM Open Account by using the following link: http://www.crmlsi.com/wordpress/loginorder/open-new-account/CRM Account No.*Please enter your 5-digit CRM Account Number.Process Via*Reg Svc (5 Business Days)Next Day RUSH (add $25.00)Same Day RUSH (add $35.00)Please select Next Day or Same Day when regular service will not satisfy the serving constraints imposed by state statute.Add eAlertNo eAlert (no added fee)eAlert Select (add $10.00)eAlert Unlimited (add $27.50)eAlert Select: select to receive an email alert prior to estimated expiration of this notice. eAlert Unlimited: receive scheduled and on demand reports on the status of all notices with the eAlert option.RETAINAGE Included:YesNoDo any of your UNPAID INVOICES include amounts billed for Retainage?PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.