Notice of Nonpayment [FORM]

(Consult an attorney before using this form or relying on this information)



To: (name of contractor and address)
(name of surety and address)

The undersigned lienor notifies you that:
1. The lienor has furnished (describe labor, services, or materials) for the improvement of the real property identified as (property description). The corresponding amount unpaid to date is $_________ , of which $___________ is unpaid retainage.
2. The lienor has been paid to date the amount of $_________ for previously furnishing (describe labor, services, or materials) for this improvement.
3. The lienor expects to furnish (describe labor, services, or materials) for this improvement in the future (if known), and the corresponding amount expected to become due is $____________ (if known).
I declare that I have read the foregoing Notice of Nonpayment and that the facts stated in it are true to the best of my knowledge and belief.
DATED on _____________, ___________.

(name, company, signature and address of lienor)

COUNTY OF _____________
The foregoing instrument was sworn to (or affirmed) and subscribed before me this _____ day of ____________, ________, by (name of signatory).

(Signature of Notary Public – State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)

Personally Known OR Produced Identification
Type of Identification Produced