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Required fields are marked with asterisks (*)

Claim for Lien Submission

Claim for Lien - Form 12

Under Section 34 of the Construction Act, R.S.O. 1990, c. C.30

This form may contain personal information as defined under the Municipal Freedom of Information and Protection of Privacy Act. This information is collected under the legal authority of the Municipal Act, 2001, S.O. 2001 c.25, as amended. This information will be used and maintained by the City of Oshawa for. Questions regarding this collection may be directed to the City’s Information Access and Privacy Officer at 905-436-3311

Name of lien claimant

(In the case of a claim on behalf of a worker by a workers' trust fund, the name of the trustee)

Address for service

Name of owner

Address

Name of person to whom lien claimant supplied services or materials

Address

Time within which services or materials were supplied

From (date supply commenced)

To (date of most recent supply)

Short description of services or materials that have been supplied

Contract price or subcontract price

Amount claimed as owing in respect of services or materials that have been supplied

Use A where the lien attaches to the premises; use B where the lien does not attach to the premises

A. The lien claimant (if claimant is personal representative or assignee, this must be stated) claims a lien against the interest of every person identified above as an owner of the premises described in Schedule A to this claim for lien.

B. The lien claimant (if claimant is personal representative or assignee, this must be stated) claims a charge against the holdbacks required to be retained under the Act and any additional amount owed by a payer to the contractor or any subcontractor whose contract or subcontract was in whole or in part performed by the services or materials that have been supplied by the lien claimant in relation to the premises at:

(Address or other identification of the location of the premises)

Date

Signature

Schedule A

To the claim for lien of

Description of premises

(Where the lien attaches to the premises, provide a description of the premises and address sufficient for registration under the Land Titles Act or the Registry Act, as the case may be. Where the lien does not attach to the premises, the address or other identification of the premises)