Ministry of
Transportation
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Claim for Lien
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Name of lien claimant
Is claimant a
Date (yyyy/mm/dd)
Personal Representative
Assignee
Address for Service
City/Town/Village
Name of owner:
Province/State
Country
Postal/Zip code
Contract Number
Her Majesty The Queen in Right of
Ontario as represented by the
Minister of Transportation
Name of person to whom lien claimant supplied services or materials
Address
City/Town/Village
Province/State
Country
Postal/Zip code
Time within which services or materials were supplied
From (Date Supply Commenced)
To (Date of Most Recent Supply)
(yyyy/mm/dd)
(yyyy/mm/dd)
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
$
$
The lien claimant 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 to any subcontractor whose contract or subcontract was in whole or in part performed by the
services or material that have been supplied by the lien claimant in relation to the contract
Location of Contract
Signature of Claimant or Agent
Date (yyyy/mm/dd)
Affidavit of Verification of Lien Claim
I,
make an oath and say (or affirm) as follows:
Use A, B, or C as applicable
A.
1. I am the lien claimant named in the claim for lien;
2. The facts stated in the claim for lien are true.
B.
1. I am the agent (or assignee) of the lien claimant named in the claim for lien;
2. I have informed myself of the facts stated in the claim for lien, and I believe those facts to be true.
C.
1. I am a trustee of the workers' trust fund which is named as the lien claimant in the claim for lien;
2. I have informed myself of the facts stated in the claim for lien, and I believe those facts to be true.
Sworn (or affirmed) before me at the
of
}
in the
of
}
this
day of
20
}
Signature of Deponent
}
A Commissioner, etc.
Claims for a lien may be preserved by sending this form by hand or by registered mail to the:
Director, Legal Services Branch
Ministry of Transportation
Main Floor, Bldg. “B”
1201 Wilson Avenue
Downsview ON M3M 1J8
023-0127 (02/2007)
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