Lien Submission Form Use this form below so we can start your lien today! Once completed, one of our representatives will contact you. Note: if you have already submitted this form and just need to make a payment to us, please visit our payment options. By submitting this form, I hereby certify under penalty of perjury that the information entered by me on this document is true and correct and I have no information or belief that there is a valid defense to the claims which give rise to the lien(s). I have verified the below vehicle for correct valuation, license plate and vehicle identification numbers. Independent Lien Service will assume no responsibility for illegible or missing information. I appoint Independent Lien Service as Power of Attorney and authorize Independent Lien Service or its employees to sign on my behalf for the purpose of a lien sale on the below vehicle. Company Information Company Name: Address: City: Zipcode: (5 digits) State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Daytime Phone: Email: gastropod Vehicle/Vessel Information Customer/Owner of Vehicle: Customer Address: Customer City: Customer Zipcode: (5 digits) Customer State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Is the Vehicle/Vessel in your possession? Yes No Date of Possession: Date of Repair Completion: (if applicable) License Plate or CF Number: License State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Make: Model: Year: VIN or Hull Number: Motorcycle Engine Number: (if applicable) Repair Shop Bar Number: (required if charging repairs) Repair Amount: Daily Storage Charge: Vehicle Value: Under $4000 Over $4000 Vessel Value: Under $1500 Over $1500 gastropod Other Information How did you hear about us? Search Engine Direct Mail Merchant Circle Referral by Friend Referral by business associate Other Comments: Please enter your full name for authorization of this lien sale submission. This will act as your signature. Note: The Yellow boxes are required fields and must be completed. If you have already submitted this form and just need to make a payment to us, please visit our payment options. gastropod Thank You,The Independent Lien Service Department Independent Lien Service 415-706-6344 voice line 707-774-6469 fax line