Final Lien Request Form – Fill Out and Use This PDF

HUMAN RESOURCES ADMINISTRATION

INVESTIGATION, REVENUE AND ENFORCEMENT ADMINISTRATION

DIVISION OF LIENS AND RECOVERY

P.O. BOX 3786 - CHURCH STREET STATION

NEW YORK, NY 10008-3786

Telephone: (212) 274-5892

UPDATED / FINAL LIEN REQUEST

FAX FORM

FAX #: (212) 274-4988 OR (212) 274-5603

Date:

(I.)

Plaintiff Name:

SSN:

Date of Birth:

Settlement Amount:

Date of Incident:

NYC File Number (if action against NYC):

Settlement Date:

Index Number:

Case Number or CIN:

Specify Injury: (E.G. Ankle Fracture), or Fax Bill of Particulars:

Type of Lien (circle one):		Updated	Final
(II.) Attorney requesting lien represents (circle one):			Plaintiff		Defendant
Firm Name:
Firm Address:
Telephone:			Fax:
Attorney Name:			E-mail:
Conference Date:

(III.) If the requesting attorney represents the plaintiff, please provide the Defendant’s name, Defendant’s attorney’s name, address and phone number. If representing the Defendant, please provide the Plaintiff’s name, Plaintiff’s attorney’s name, address and phone number.

1.

2.

(IV.) Provide the Name and Address of each Insurance Company insuring each Defendant named above. Include Insurance Company Claim/File for each.

1.

2.

(V.) Completed by:

Date: