Retainage Agreement Request Retainage Agreement Request Used to protect your rights to claim a mechanics lien on the unpaid retainage held until all contract terms are satisfied Notice State*Please selectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState for which this notice is requestedType of ImprovementPlease identify type of constructionNew Residential ConstructionNew Commercial ConstructionResidential Repairs/AlterationsCommercial Repairs/AlterationsOther - please explain in description fieldPlease select the type of work being constructedDate Requested Process Via*Reg Svc (5 Business Days)Next Day RUSH (add $27.00)Same Day RUSH (add $37.00)Please select Next Day or Same Day when regular service will not satisfy the serving constraints imposed by state statute.Add eAlert to this requestPlease Select your eAlert PreferenceNo eAlert (no added fee)eAlert Select (add $10.00)eAlert Unlimited (add $27.50)eAlert Select: a "One Time" email alert sent prior to the expiration of your lien rights. eAlert Unlimited: a series of managed eAlerts which adjust as the project progresses. without eAlert: No eAlerts will be sentUnlimited option.Send my copy of the final notice using:*Please choose how you want to receive your copy of the served noticeeCopy - send email on date servedeGreenies - upload to my eGreenies online accounteSystems - upload to my eSystems online accountHard Copy - include with my monthly statementDo not send any copies of my served noticesPlease select how you would like to copied for your served noticeMy Company InformationThe following is my company information:Company Name*My Company: NameAuthorized by:*Name of person in your company who is authorizing this Retainage AgreementTitle of Authorized Representative*The title of the person in your company who has authorized this Retainage AgreementMy Email* My Company: Contact eMailAddress Line 1*My Company: Street AddressAddress Line 2My Company: PO Box, Suite #Address Line 3My Company: Building Reference, Floor, Attn:City*My Company: CityState*ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYMy 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:The Project is known as:*Please include the name by which this project is knownApproved Retainage*The amount allowed by this agreement to be withheld as RetainageRetainage Terms*The number of days and conditions, upon which your withheld Retainage will become due and payable.Address 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: ZIPStart 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 description of the materials, labor, or services you will provide to this project. Please limit to 120 characters.Customer InformationThe following is my customer information My Customer's Name*My Customer's Designation*Please identify your customer's position for this projectGeneral ContractorProperty OwnerTenantSub ContractorPlease identify the appropriate designation of your customer on this projectContact First NameMy Customer: Contact First NameContact Last NameMy Customer: Contact Last NameEmail My Customer's: eMail Address - REQUIRED if you want your customer to receive a COURTESY eMail copy of the served notice!Address 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:Please Select StateZip*My Customer's: ZIPMain Phone*My Customer's: Main Phone NumberCell PhoneMy Customer's: Cell Phone NumberProperty Owner InformationThe following is the Property Owner information (In many states the law requires the Property Owner to comply with the Retainage directive. However, any owner may opt to make Retainage a condition of the construction contract)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: CityStateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYProperty Owner:Please Select StateZIPProperty Owner: ZIPMain PhoneProperty Owner: Main PhoneCell PhoneProperty Owner: Cell PhoneFaxProperty Owner: FAXProperty Use Is*ResidentialNon-ResidentialCommercialIndustrialTribal LandOtherUnknownPlease identify the classification or identification of the type of work being done.Please 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.Place this order using my CRM AccountPlease 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 Number*Please enter your 5-digit CRM Account Number.PhoneThis field is for validation purposes and should be left unchanged.